Child And Adult Care Food Program Child Enrollment Form printable pdf download

OMER Roster Number ________

Child and Adult Care Food Program CHILD ENROLLMENT FORM

Child Care Centers/Head Start Programs

_____________________________________________

CACFP Sponsor Name/Site Name

TO BE COMPLETED BY PARENT/GUARDIAN ONLY

The CACFP reimburses centers for serving nutritious, well-balanced meals and snacks to children in care.

Complete the following chart for all children in care. Sign, date, and return to the center. Use additional forms, as needed.

Parents/guardians of all infants must complete the Infant Formula Selection section.

Normal Hours in Care

Enter the time

Children’s Names

Normal Meals and Normal Days in Care

your child

usually arrives

usually leaves

each day.

Normal Meals While In Care

Breakfast AM Snack Lunch PM Snack Supper Eve Snack

Last:

____________

Time

Normal Days of the Week in Attendance

Mon

Tue

Wed

Thu

Fri

Sat

Sun

First

Normal Meals While In Care

Breakfast AM Snack Lunch PM Snack Supper Eve Snack

Last

____________

Time

Normal Days of the Week in Attendance

Mon

Tue

Wed

Thu

Fri

Sat

Sun

First

Normal Meals While In Care

Breakfast AM Snack Lunch PM Snack Supper Eve Snack

Last

____________

Time

Normal Days of the Week in Attendance

Mon

Tue

Wed

Thu

Fri

Sat

Sun

First

Normal Meals While In Care

Breakfast AM Snack Lunch PM Snack Supper Eve Snack

Last

____________

Time

Normal Days of the Week in Attendance

Mon

Tue

Wed

Thu

Fri

Sat

Sun

First

Parent/Guardian Print Name:

Date

_________________________________________________________________

_______________

Parent/Guardian Signature: _________________________________________________________

INFANT FORMULA SELECTION: Complete if any child listed above is an infant under one year of age

This center provides ______________________________________________ (list brand) iron fortified infant formula.

Check one:

I accept the center provided formula

I decline the center provided formula

I understand that by declining the center provided formula, I agree to provide breast milk or formula for my child.

If I provide formula it must be on the approved formula list for the center to be reimbursed for the meal.

The parent/guardian signing this form certifies that the enrollment information is correct. If information has

Updates:

changed, the parent/guardian has written the appropriate changes on the form and initialed the change.

(annual at a minimum)

If there are many changes, please complete a new form.

First Update

Parent/Guardian Signature

Date

Second Update

Parent/Guardian Signature

Date

Third Update

Parent/Guardian Signature

Date

Fourth Update

Parent/Guardian Signature

Date

USDA and this institution are equal opportunity providers and employers.

Child Enrollment Form – Centers

Child And Adult Care Food Program Child Enrollment Form

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