Cacfp Enrollment Form Page 2
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1
2CACFP Enrollment Form (sample #2)
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.
(Select one or
(Please circle all that apply)
more)
Full Name(s) of Enrolled
* Race/
Date of
Normal Hours In
Meals Normally Eaten
Normal Days of Care
Child(ren)
Ethnicity
Birth
Care
While at the Facility **
M
T
W T
F
S
S
B
AM
L
PM
Su
Ev
to
M
T
W T
F
S
S
B
AM
L
PM
Su
Ev
to
M
T
W T
F
S
S
B
AM
L
PM
Su
Ev
to
M
T
W T
F
S
S
B
AM
L
PM
Su
Ev
to
to
M
T
W T
F
S
S
B
AM
L
PM
Su
Ev
* Race: Hispanic or Latino
Ethnicity: American Indian or Alaskan Native / Asian / Black or African American / Native Hawaiian or other Pacific Islander / White
** B = Breakfast
AM = AM Snack
L = Lunch
PM = PM Snack
Su = Supper
Ev = Evening Snack
List any holidays that may require care: ___________________________________________________________________________
Special needs or instructions (i.e. allergies): ________________________________________________________________________
Parent/Guardian’s Name: ___________________________________________________________ Phone Number: ______________
Home Address: _______________________________________________ City: ________________ State: ______ Zip: __________
Mother’s Employer: _______________________________________________________________ Phone Number: ______________
Father’s Employer: ________________________________________________________________ Phone Number: ______________
Family Doctor: ______________________________________ In Emergency Call: ________________________________________
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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