Child Enrollment Form
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1Child and Adult Care Food Program
Child Enrollment Form
Enrollment Date:
Child
______________________________________
Parent/Guardian ___________________________
Address ______________________________________
Address ____________________________________
______________________________________
____________________________________
Birth date ____________________
Telephone (home)___________(work)____________
Sponsoring Organization ________________________
Center/Home _______________________________
Address _______________________________________
Address ____________________________________
_______________________________________
____________________________________
Normal Hours of Care (write in times)*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Start:
Start:
Start:
Start:
Start:
Start:
Start:
End:
End:
End:
End:
End:
End:
End:
* If more than 8 hours of care per day, please attach an explanation to this form.
Daily Expected Meal Service Participation (please check box)
Breakfast
AM Snack
Lunch
PM Snack
Supper
Eve Snack
Is this child of school age? ___Yes ___No
If yes, will additional meals be provided when school is not in
session? ___Yes ___No
If yes, please specify the meal: ___Breakfast ___Lunch ___Snack ___Supper
Parental Contacts:
This child care facility participates in the Child and Adult Care Food Program. In
order to receive federal funds, representatives of the sponsoring organization or the State Agency may
contact you to verify your child’s participation. Please indicate what time and method of contact you
prefer:
Time
_____Day
_____Evening
_____
_____Letter
_____Telephone (home)
_____Telephone (work)
Signature _________________________________
Date _______________________
Parent/Guardian
Signature _________________________________
Date _______________________
Center Administrator/Home Provider
“In accordance with Federal law and U. S. Department of Agriculture policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, age or disability. (Not all prohibited bases apply to all
programs). ”
“ To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400
Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal
opportunity provider and employer.”
For Sponsor Use Only
Child withdrew on _______________________________________________________
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