Day Care Center Enrollment Form

ADVERTISEMENT

CACFP Agreement # 3409
DAY CARE CENTER ENROLLMENT FORM
Center Name: CORTELYOU EARLY CHILDHOOD CENTER
Child’s Name: _____________________________________________________________________________________
Male ______
Female _______
Date of Birth ___________
Home Phone ___________________________
Home Address _____________________________________________________________________________________
Mother/Guardian Name ______________________________________________________________________________
Father/Guardian Name _______________________________________________________________________________
Parent/Guardian Address and Phone, if different ___________________________________________________________
In case of emergency, notify _______________________________________
Phone ___________________________
Second person to notify ___________________________________________
Phone ___________________________
Physician’s name ________________________________________________
Phone ___________________________
TIME MEALS SERVED
Breakfast______ am to ______am
Lunch ______am/pm and ______pm
Afternoon Snack _____pm to _____pm
If your child is in care during these times, he/she will receive the meal or snack that is being served.
What days will your child usually be at the center?
M____ Tu _____ W ____ Th _____ F____ Sat____ Su _____
What hours will your child usually be at the center?
Arrive_________
am
pm
Depart _________
am
pm
Signature of a parent/guardian ____________________________________________
Date _____________________
   
After 1 year of care
Is all the information above still correct?
Yes ________ No ________
If no, what has changed? _____________________________________________________________________________
Signature of a parent/guardian ____________________________________________
Date _____________________
CACFP-169 (7/09)
Page 1 of 1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Education
Go