Child Enrollment Form For Head Start Centers - 2016 printable pdf download

Child and Adult Care Food Program (CACFP)

CHILD ENROLLMENT FORM FOR HEAD START CENTERS

Our child care center participates in the U.S. Department of Agriculture (USDA) Child and Adult Care Food

Program (CACFP). This program helps us provide nutritious meals and snacks to children enrolled in our center.

For information on the CACFP meal pattern requirements, see the

CACFP Meal Pattern for Children

and the

CACFP Infant Meal Pattern

SECTION 1 – WAIVER OF CACFP PARTICIPATION

Check here ONLY if you are choosing not to enroll your child in the CACFP. Complete section 3 on page 2, and

return to the child care center.

I do not want my child to participate in the CACFP.

SECTION 2 – CACFP ENROLLMENT

To verify your child’s enrollment in this child care center, complete this section and section 3 on page 2, and return

to the child care center. You may be contacted by the center, the Connecticut State Department of Education or the

USDA to verify this information.

Please print all information.

Child Care Center’s Name:

Child’s Name:

Birth Date:

Last Name

First Name

Month, day, year

Male

Female

First Day of Attendance:

Complete the chart below. My child will normally be in child care during the following days and times, and will

receive the meals indicated below.

Days and Hours of Care and Meals Served

Normal

Days of

Care

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Check all

that apply

______ AM/PM

Normal

_____

AM/PM

Hours in

Care

and

Circle AM

______ AM/PM

or PM

_____

AM/PM

Breakfast

Meals

AM Snack

normally

served

Lunch

to my

PM Snack

child

Supper

Check all

Evening

that apply

Snack

Connecticut State Department of Education  Revised April 2016  Page 1 of 2

Child Enrollment Form For Head Start Centers - 2016

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