Food For Kids Enrollment Form

FOOD FOR

INC

_______________________________________________ participates in CACFP with

Complete Name of Day Care Center or Day Home Provider

The following enrollment information is required because your child participates in Child & Adult Care Food Program.

Add Date: _______________

Indicate Child’s Normal

Resident

Indicates Normal

Date of

Time in

Last Name

First Name

ial child

2

Meals Child

Days of Care (circle)

Birth

Care

(check if

Receives

(circle)

live with

1

Begin - End

provider)

M Tu W Th F S Su

B AM L PM S Ev

-

M Tu W Th F S Su

B AM L PM S Ev

-

M Tu W Th F S Su

B AM L PM S Ev

-

M Tu W Th F S Su

B AM L PM S Ev

-

M Tu W Th F S Su

B AM L PM S Ev

-

B – Breakfast AM – AM snack L – Lunch PM – Afternoon Snack S – Supper EV – Evening Snack

2 Only Day Home Providers

1

School Age children normal times: Leave for school: ____________ Return from School: ___________

:

Civil Rights statistical Report: This information is used for statistical reports only to be sure everyone receive meals fairly and without discrimination

Ethic Category:

Hispanic or Latino ___

Not Hispanic or Latino___

Racial Category:

___ American Indian or Alaskan Native ___ Native Hawaiian or Other Pacific Islander ___ White ___ Asian ___ Black or African American

Breast Milk and Iron-Fortified Infant (IFIF)

Your day care center is required to offer Iron-Fortified Formula (IFIF) to your

You must complete this entire section if the child is under 1 year old.

infant and must inform you of the brand offered. It is your choice whether or

Brand of iron-Fortified infant formula (IFIF) offered by Day Care Center /Day

not to use this formula based on your preference and your infant’s need. You

may choose to supply breast milk or formula for your infant.

Home Provider: ________________________________

If you accept the formula offered by the provider, you give your permission for

the formula to be mixed for your infant by the facility staff.

Low or non-iron fortified infant formula from provider or parent requires a doctor’s statement.

If you refuse the provider’s formula and choose to supply formula for your

The IFIF/Breast Milk & Food Options have been explained, parent has reviewed infant

infant, you must write the brand of formula you will be supplying in the space

:

and CACFP information given on this form, and the parent has chosen

provided on the front of this form and mark the “parent supplies breast milk or

IFIF” option on the from of this form. If the formula you provide is low-iron

fortified, non-iron fortified, or specialty formula, a medical statement is

Choose ONE IFIF/Breast Milk Option:

required.

_____ Day Care Center/Provider supplies IFIF

_____ Parent supplies Breast Milk brand in

Note to parents who receive formula through the WIC program:

(parents accepts or IFIF brand above)

space below or IFIF

Your infant is eligible to receive formula to use when in child care. If you

______________________________________Brand of iron-fortified formula (IFIF) from parent

decided that your infant will use the formula from the WIC program at this

(write name of formula)

child care facility, on the front of this form mark the “parent supplies breast

Choose ONE Infant Foods Option:

milk or IFIF” option and write the brand name of the WIC formula in the space

provided. If you find that you are getting more formula than your infant needs,

_____ Day Care Center/Provider supplies supplemental

_____ Parent supplies supplemental

you should contact your WIC nutritionist.

foods when developmentally appropriate

foods & refuse the day care centers/

providers foods

Supplemental Foods

When your infant is four (4) months old or older and is developmentally ready

for baby food, your day care center is required to offer additional, supplemental

foods in compliance with the infant meal pattern as required by USDA. These

foods will include iron-fortified cereal, fruits, vegetables, meats and meat

Day Care Center/Provider has provided me with a copy of:

alternates, when developmentally appropriate for your child. You have the

 Building Better Future Brochure  Income Eligibility Letter WIC Info

option of supplying these supplemental foods and refusing the provider’s

supplemental foods. Please indicate your choice in the infant section on the

front of this form

________________________

Print/Guardian Parent Complete Name:

Parent/Guardian Signature: _________________________________ Date: _________________

Home Address ____________________________________________

City __________________

TX

Zip __________Email address: _____________________________

Work Tel ____________________ Alternate Tel ______________________

The U.S Department of Agriculture prohibits discrimination against bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital

Update: 102115

status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program.