Cacfp Enrollment Form
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1
2CACFP Enrollment Form (sample #1)
Please complete and/or update and sign this form and return it to _______________________________ no later than ____________.
Our agency participates in the Child and Adult Care Food Program (CACFP) and receives Federal reimbursement for the meals
served to your child(ren). The Federal regulations for the CACFP require us to collect and update this information on an annual basis
for all of our enrolled children. This information is used to confirm your child(ren)’s current enrollment in the center and thus in the
CACFP. All information is confidential and will be shared with appropriate personnel and state/federal staff as needed. Note: The
indication of racial and ethnic background is optional and will not affect eligibility for the Program. This information is used for
reporting purposes only. By providing this information you will assist us in assuring that this program is administered in a
nondiscriminatory manner. If racial / ethnic background is not reported, a visual identification of the child’s race and ethnicity will be
made.
Child’s Name:
Sex
M F Date of Birth:
/
/
Foster Child?
:
Y
N
First
Middle
Last
(circle)
Hours normally in care:
to
Circle days of week normally in care:
M T W T F S S Holidays
Circle meals normally eaten in care:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Eve Snack
Date Enrolled:
Date Terminated:
Select One or More:
Hispanic or Latino
Not Hispanic or Latino
Ethnicity:
American Indian / Alaskan Native
Asian
White
Race:
Native Hawaiian / Pacific Islander
Black or African American
Child’s Name:
Sex
M F Date of Birth:
/
/
Foster Child?
:
Y
N
First
Middle
Last
(circle)
Remainder of the information is the same as above (or list child’s name):
Hours normally in care:
to
Circle days of week normally in care:
M T W T F S S Holidays
Circle meals normally eaten in care:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Eve Snack
Date Enrolled:
Date Terminated:
Select One or More:
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
American Indian / Alaskan Native
Asian
White
Race:
Native Hawaiian / Pacific Islander
Black or African American
Parent Signature: _____________________________________________________________________ Date: ________________
Annual Updates (to be completed on an annual basis after initial enrollment):
st
1
Annual Update
I have reviewed the enrollment information for my child(ren) and (check one): found it to be accurate at the present time
made changes as needed
Parent Signature: _________________________________________________________________
Date: ________________
nd
2
Annual Update
I have reviewed the enrollment information for my child(ren) and (check one): found it to be accurate at the present time
made changes as needed
Parent Signature: _________________________________________________________________
Date: ________________
rd
3
Annual Update
I have reviewed the enrollment information for my child(ren) and (check one): found it to be accurate at the present time
made changes as needed
Parent Signature: __________________________________________________________________
Date: ________________
“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. To file a complaint of discrimination, write USDA, Director, Office of Civil
Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TTY).
USDA is an equal opportunity provider and employer.”
Office use Only: Enrollment Date: _______________
Update Date: _______________
Dismissal Date: _______________
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