Cacfp Enrollment Form Options Page 4
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5Ohio Department of Education - Office for Child Nutrition
EXAMPLE B
CHILD AND ADULT CARE FOOD PROGRAM ENROLLMENT FORM
Prototype Form for use by Child Care Centers and Head Start Programs
CACFP programs exempt from having an enrollment form on file are: Emergency Shelters, Outside-School-Hours, Youth Development & After School At Risk
Instructions for Completion
•
All parents/guardians are to complete a separate form for each child enrolled at the child care or Head Start center.
•
List the child’s name, age, birth date, the days and hours normally in care and the meals normally received while in care. If schedule will vary in future due to changes
in parent/guardian job schedule, indicate by writing a note on chart.
•
If the child comes before and after school, list the hours in care for both the morning and afternoon.
•
CACFP Federal regulations 226.15(e)(2) require that an enrollment form be updated annually and signed by the child’s parent or guardian.
CENTER NAME
Nashville Child Care
CHILD’S NAME
AGE
BIRTHDATE
6
/
1
/
06
(please print)
Amy Smith
4
month
/
day
/
year
CHECK THE NORMAL DAYS AND HOURS YOUR CHILD IS IN CARE AND THE MEALS RECEIVED WHILE IN CARE
Check () Days Child
List Hours Child Normally in Care
Check () Meals Child Normally Receives while in Care
Normally
AM
PM
Evening
in Care
Arrive
Depart
Arrive
Depart
Breakfast
Snack
Lunch
Snack
Supper
Snack
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
SIGNATURE OF
DATE
DAY PHONE
PARENT/GUARDIAN
Mary Smith
2/15/2011
NUMBER
614-987-6543
MAILING ADDRESS:
STREET /APT.
123 Park Street
CITY
Nashville
ZIP CODE 44448
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 Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 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.
(rev. 2/23/11)
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