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

Child and Adult Care Food Program (CACFP)

Participant Enrollment Form

Institution Name: ______________________________________

Agreement Number: ___________

Facility/Provider Name:_________________________________

Dear Parent/Guardian,

Your day care facility participates in the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program

(CACFP). CACFP needs verification of enrollment for each participant in this facility. Please complete the table below

for all participants in your household that are enrolled at this facility. The information below should be completed by the

parent or guardian. Please use the guides below the table to complete. Please sign and date this form below.

Participant’s First

Participant’s Last

Date of

Normal/Typical

Normal/Typical Days of

Meals Normally

Name

Birth

Hours of Care

Care

Eaten

(Circle all that apply)

______ to ______

M T W TH F Sat Sun

B AM L PM S LPM

______ to ______

M T W TH F Sat Sun

B AM L PM S LPM

______ to ______

M T W TH F Sat Sun

B AM L PM S LPM

______ to ______

M T W TH F Sat Sun

B AM L PM S LPM

______ to ______

M T W TH F Sat Sun

B AM L PM S LPM

Guide:

Normal hours of care: Please insert the usual arrival time and the usual departure time. Indicate a.m. or p.m.

Normal days of care: Please circle the days of the week the participant(s) are usually in attendance at the facility.

(M=Monday; T=Tuesday; W=Wednesday; TH= Thursday; F=Friday; Sat =Saturday; Sun=Sunday)

Meals Normally Eaten – Please circle the meals the participant(s) usually eats at the facility.

(B=Breakfast; AM=AM Snack; L=Lunch; PM=PM Snack; S=Supper; LPM=Late PM/Evening Snack

Parent/Guardian Signature: ____________________________________

Date: _____________

Print Name: ___________________________________________

Address: _____________________________________________________________________

City: ___________________________________________ State: _____ Zip Code: _________

Home Telephone Number: (

) ________________

Work Telephone Number: (

) ________________

For Facility/Provider Use Only:

Signature of Facility Representative/Provider: _______________________________________________ Date: ______________

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. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-

9410 or call (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.

For State Use Only: Complete: _______ Incomplete _______

Reason: ______________________

Verified by:__________________ Date:__________

DHHS CAC-Enrollment (2/11)