Child And Adult Care Food Program (Cacfp) Adult Participant Enrollment/information Form printable pdf download

Institution Name: ___________________________________

Agreement Number: ___________

Facility Name: _____________________________________

Child and Adult Care Food Program (CACFP)

Adult Participant Enrollment/Information Form

A. Participant Information

Participant’s Name:

Participant’s Age:

Is the adult participant 60 years of age or older? (Check one)

Yes

Is the adult participant a “functionally impaired adult”? (Check one)

Yes

7 CFR §226.2 defines “functionally impaired adult” as “chronically impaired disable persons 18 years of age or older,

including victims of Alzheimer’s disease and related disorders with neurological and organic brain dysfunction, who are

physically or mentally impaired to the extent that their capacity for independence and their ability to carry out activities of

daily living is markedly limited. Activities of daily living include, but are not limited to, adaptive activities such as

cleaning, shopping, cooking, taking public transportation, maintaining a residence, caring appropriately for one’s

grooming or hygiene, using telephones and directories, or using a post office. Marked limitations refer to the severity of

impairment, and not the number of limited activities, and occur when the degree of limitations is such as to seriously

interfere with the ability to function independently.”

B. Participant’s Residence Information

Does the adult participant reside in his/her own home? (Check one)

Yes

If the adult participant does not reside in his/her own home does the

adult participant reside in a “group living arrangement”? (Check one)

Yes

7 CFR §226.2 defines “group living arrangement” as “residential communities which may or may not be subsidized by

federal, State or local funds but which are private residences housing an individual or a group of individuals who are

primarily responsible for their own care and who maintain a presence in the community but who may receive on-site monitoring.”

If the adult participant does not reside in his/her own home or in a “group living arrangement”

please describe the type of residence: ____________________________________________

___________________________________________________________________________

Participant/Guardian Signature: ________________________________________

Date: ____________

Print Name: ____________________________________________________________

Address: _____________________________ City: _______________ State: _______ Zip Code: ____________

Home Telephone Number: (

) ____________________________________________

Work Telephone Number: (

) ____________________________________________

For Institution Use Only:

Signature of Institution’s Representative: ___________________________________

Date: _______________

Date the participant enrolled: _________________________

Date the participant withdrew: ________________________

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. (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write USDA,

Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382

(voice and TTY). USDA is an equal opportunity provider and employer.”

CACFP

Adult Enrollment/Information Form

11/09

Child And Adult Care Food Program (Cacfp) Adult Participant Enrollment/information Form

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