Child & Adult Care Food Program Form

Minnesota Licensed Family Child Care Association

Child & Adult Care Food Program

1821 University Ave West  #324 South  Saint Paul MN 55104

Phone 651-636-1989 (Outside Metro Area) 1-800-652-9704

Social Security Number: __________________________________

Legal Name

Of Provider: _______________________________________________________

Telephone # (area code): (_________)_______________________

FIRST

MI

LAST

Date of Birth (required by USDA): __________________________

Address: _________________________________________________________

County: _______________________________________________

City: ________________________________________ MN Zip: ______________

E-mail: ________________________________________________

CHILD CARE DATA:

Fax Number (area code): _______________________________

Average number days per week that food will be served:

Circle Days of Operation: Mon Tues Wed Thurs Fri Sat Sun

Number of weeks per year that child care is provided:

Hours of operation: From:

To:

Ages of children in care: From:

Through:

Average daily attendance (including own children):

LICENSE DATA:

License number:

License class/capacity (from license):

License availability (check one):

 License posted in home  In process of relicensure

License Dates: valid from:

to:

New Provider: License applied for on__________________

Handicapped Care:

Yes

No

Provider’s own children under age 13:

NAME

AGE

BIRTHDATE

_______________________________________

__________

__________________________

_______________________________________

__________

__________________________

_______________________________________

__________

__________________________

FOOD SERVICE DATA

Check the meals and snacks you plan to serve (you can be reimbursed

Average

Serving Hours

only for those checked and for no more than two meals and one snack per

Participation

From

To

child per day or one meal and two snacks per child per day).

Breakfast

Morning Snack

Lunch

Afternoon Snack

Supper

Evening Snack

VOLUNTARY CIVIL RIGHTS

SPONSOR USE ONLY

Check the box that best describes your racial or ethnic identity. This information is voluntary

N________________________

and will not affect eligibility.

W_______________________

Choose one:  Hispanic/Latino

 Not Hispanic/Latino

Tier 1: Yes No School Census

Then Choose:  American Indian

 Alaskan Native

 Asian

 Pacific Island

 Black  White

FNS #: 90000______________

 I do not wish to give this information

 Noted by Representative

(Note: If you choose not to volunteer this information, your Representative must choose a category

Approval Date: ____________

for you. Information is gathered only for statistical information.)

I certify that to the best of my belief and knowledge, the information on this Child & Adult Care Food Program Family Child Care Application is correct in all respects. I certify that the Program will

be made available to all eligible children regardless of race, color, sex, age, handicap or national origin. I understand that this application will be verified and that deliberate misrepresentation

may subject me to prosecution under applicable State and Federal criminal statues. I am not currently participating or applying to participate in the CACFP with any other sponsor.

In accordance with Federal law and US Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a

complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue SW, Washington DC 20250-9410 or call toll-free (866) 632-9992 (Voice). Individuals who

are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (Spanish). USDA is an equal opportunity provider

and employer.

Date

Provider Signature

Monitor Signature

_______________

_____________________________________

_______________________________