Form Isbe 67-98 - Annual Enrollment Form
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1ILLINOIS STATE BOARD OF EDUCATION
Annual Enrollment Form
Child and Adult Care Food Program
This form is required for Child Care Centers, Pre-K, Head Start, Even Start, and Licensed Outside School Hours Programs.
This form is NOT required for At-Risk After-School, License-exempt Outside School Hours, or Emergency Shelters.
Parents/Centers: This institution participates in the Child and Adult Care Food Program (CACFP) and receives reimbursement to provide more nutritious
meals for your child(ren). Federal CACFP regulations require all parents or guardians to complete or review a CACFP Annual Enrollment Form when enrolling
their child(ren) and every year thereafter. This information will help ensure all children receive appropriate meals during their care. The parent or center may
complete Sections 1 through 4. The parent must review to ensure accuracy; then complete Section 5, sign and date Section 6. If parent does not complete
Section 5, center staff should complete to the best of their ability (by observation) and initial the section. The center will review completed enrollment form.
1
2
3
4
DAYS OF WEEK
FULL NAME OF ENROLLED CHILD
MEALS RECEIVED
TIMES CHILD NORMALLY ATTENDS DURING WEEK
(Include Birth Date/Age)
IN ATTENDANCE
Monday
Early Morning Snack
TIMES CHILD ATTENDS
First Child
TIME IN
TIME OUT
SCHOOL
Tuesday
Breakfast
Name
Leaves
Returns To
Wednesday
A.M. Snack
AM
PM
TIME
AM
PM
TIME
Center
Center
Thursday
Lunch
Birth Date
Friday
P.M. Snack
Yes
No I work multiple shifts and child(ren) may be in care
Saturday
Supper
Age
different days/hours
Sunday
Evening Snack
Same Days as
Second Child
Same Times as Child Above
Same Meals as Above
Above
Monday
TIMES CHILD ATTENDS
Early Morning Snack
TIME IN
TIME OUT
SCHOOL
Tuesday
Breakfast
Name
Leaves
Returns To
Wednesday
A.M. Snack
AM
PM
TIME
AM
PM
TIME
Center
Center
Thursday
Lunch
Birth Date
Friday
P.M. Snack
Yes
No I work multiple shifts and child(ren) may be in care
Saturday
Supper
Age
different days/hours
Sunday
Evening Snack
Same Days as
Third Child
Same Times as Child Above
Same Meals as Above
Above
Monday
TIMES CHILD ATTENDS
Early Morning Snack
TIME IN
TIME OUT
SCHOOL
Tuesday
Breakfast
Name
Leaves
Returns To
Wednesday
A.M. Snack
AM
PM
TIME
AM
PM
TIME
Center
Center
Thursday
Lunch
Birth Date
Friday
P.M. Snack
Yes
No I work multiple shifts and child(ren) may be in care
Saturday
Supper
Age
different days/hours
Sunday
Evening Snack
Please answer both questions. This information is voluntary.
5
ETHNIC/RACIAL
A. Ethnic data of child(ren) —
Hispanic or Latino
Not Hispanic or Latino
CATEGORIES—
Mark only one.
B. Racial data of child(ren) —
Asian
Black or African American
Native Hawaiian or Other
Pacific Islander
Mark one or more that
American Indian or
White
apply.
Alaska Native
6
SIGNATURE
I certify the information ___________________________________________________
___________________________
_________________________________
above is correct.
Signature of Parent or Guardian
Date
Telephone Number of Parent or Guardian
CHILD CARE REPRESENTATIVE USE ONLY
Effective Date of this enrollment form: _____________________________________
The effective date may be made retroactive back to the first day the child participates in the CACFP as long as it occurs in the same month in which this form is received.
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.
ISBE 67-98 (4/17) Effective July 1, 2017
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