Head Start Cacfp Enrollment Form
ADVERTISEMENT
1HEAD START CACFP Enrollment Form
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 reimbursements 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: Indication of race is optional and will not affect eligibility for
the Program. This information is used for reporting purposes only.
(Please circle all that apply)
Full Name(s) of Enrolled
Date of
Normal Hours
Normal Days of Care
Meals Normally Eaten While at the Facility**
*Race
Child(ren)
Birth
in Care
______ 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 ______
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
*White/Hispanic or Latimo/Asian/American Indian/Alaskan Native/Native Hawaiian or other Pacific Islander/Black or African American/Other
**B=Breakfast AM=AM Snack L=Lunch PM=PM Snack SU=Supper Ev-Evening Snack
Does class fall on any holidays? List them
Special needs or instructions (i.e. allergies):
Parent/Guardian's PRINT Name:
Phone Number:
Parent/Guardian's SIGNATURE:
Home Address:
City:______________
State: _____ Zip: _________
9-1-05
Z:\APPS\Forms\Application and Enrollment\HS CACFP Enrollment Form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business