Enrollment Statement Child And Adult Care Food Program

Child & Youth Programs

Enrollment Statement

Child and Adult Care Food Program

____________________________________________________________

Name of Client

is enrolled at:

Name of Center:________________________________________________________________

Address:______________________________________________________________________

:_________________________________________________________

Beginning on

Month/Day/Year

Child’s normal

**If attendance time and

Please circle

days and

meals are the same Monday

meals child

hours of care.

to Friday, fill in Monday and

will

sign here.

participate in

_________________________

Monday **

_____ a.m. to _____ p.m. **

Breakfast **

Lunch** PM

Snack**

Tuesday

_____ a.m. to _____ p.m.

Breakfast

Lunch

Snack

Wednesday

_____ a.m. to _____ p.m.

Breakfast

Lunch

Snack

Thursday

_____ a.m. to _____ p.m.

Breakfast

Lunch

Snack

Friday

_____ a.m. to _____ p.m.

Breakfast

Lunch

Snack

Saturday

_____ a.m. to _____ p.m.

Breakfast

Lunch

Snack

Signature_______________________________________ Date_________________

Client/Guardian

Signature_______________________________________

Date_________________

Center Administrator

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations

and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering

USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or

reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille,

large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they

applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA

through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available

in languages other than English.

To file a program complaint of discrimination, complete the

USDA Program Discrimination Complaint

Form, (AD-

3027) found online at: , and at any USDA office, or write a

letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy

of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)

mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410;

(2)

fax: (202) 690-7442; or

(3)

email:

program.intake@usda.gov.

This institution is an equal opportunity provider.

For Center use only

Client withdrawn on ____________________________________________________________________

Revised 5/16

Enrollment Statement Child And Adult Care Food Program - 2016

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