Child And Adult Care Food Program Child Enrollment Form (Sample)

Child and Adult Care Food Program

Sponsor/Center Name:_______________________________

Child Enrollment Form (Sample)

Agreement #:_______________________________________

ENROLLMENT FORM FOR CHILDREN IN CHILD CARE (SAMPLE)

This document does not have to be completed for children in Emergency Shelters, Outside School Hours, and/or At-Risk programs. It is recommended to have new

CACFP Annual Enrollment Forms completed each year during the Household Eligibility Application renewal period. Review completed enrollment form and enter the

effective date in lower right hand section.

PARENTS: 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 and guardians to complete a CACFP Annual Enrollment Form when enrolling their child(ren) and again every

year thereafter. This information will help ensure all children receive appropriate meals during their care.

Please complete all areas to include signing and dating same.

TIMES CHILD NORMALLY ATTENDS DURING WEEK

TIME-IN

TIME OUT

TIME CHILD ATTENDS

FULL NAME OF ENROLLED CHILD

DAYS OF WEEK IN

SCHOOL

MEALS RECEIVED

(Include Birth Date/Age

ATTENDANCE

AM

PM

TIME

AM

PM

TIME

LEAVES

RETURNS

CENTER

TO CENTER

FIRST CHILD

MONDAY

TUESDAY

NAME

WEDNESDAY

Yes

No

I work multiple shifts and child(ren) may be in care different days/hours

BREAKFAST

THURSDAY

A.M. SNACK

Other:

BIRTH DATE

FRIDAY

LUNCH

SATURDAY

P.M. SNACK

AGE

SUNDAY

SUPPER

EVENING SNACK

Enrollment Date

Withdrawal Date:

:

TIMES CHILD NORMALLY ATTENDS DURING WEEK

TIME-IN

TIME OUT

TIME CHILD ATTENDS

FULL NAME OF ENROLLED CHILD

DAYS OF WEEK IN

SCHOOL

MEALS RECEIVED

(Include Birth Date/Age

ATTENDANCE

Same Times as Above

AM

PM

TIME

AM

PM

TIME

LEAVES

RETURNS

CENTER

TO CENTER

SECOND CHILD

Same as Above

Same Meals as Above

MONDAY

NAME

TUESDAY

Yes

No

I work multiple shifts and child(ren) may be in care different days/hours

BREAKFAST

WEDNESDAY

A.M. SNACK

Other:

BIRTH DATE

THURSDAY

LUNCH

FRIDAY

P.M. SNACK

AGE

SATURDAY

SUPPER

SUNDAY

EVENING SNACK

Enrollment Date:

Withdrawal Date:

TIMES CHILD NORMALLY ATTENDS DURING WEEK

TIME-IN

TIME OUT

TIME CHILD ATTENDS

FULL NAME OF ENROLLED CHILD

DAYS OF WEEK IN

SCHOOL

MEALS RECEIVED

(Include Birth Date/Age

ATTENDANCE

Same Times as Above

AM

PM

TIME

AM

PM

TIME

LEAVES

RETURNS

CENTER

TO CENTER

THIRD CHILD

Same as Above

Same Meals as Above

MONDAY

NAME

TUESDAY

Yes

No

I work multiple shifts and child(ren) may be in care different days/hours

BREAKFAST

WEDNESDAY

A.M. SNACK

Other:

BIRTH DATE

THURSDAY

LUNCH

FRIDAY

P.M. SNACK

AGE

SATURDAY

SUPPER

SUNDAY

EVENING SNACK

Enrollment Date:

Withdrawal Date:

Signature

Signature of Parent or Guardian

Date

Telephone Number of Parent or Guardian

CHILD CARE REPRESENTATIVE USE ONLY:

______________

Name of Representative/Signature

Date

The effective date can be made retroactive back to the first day the child participates in the CACFP as long as it occurs in the same month this form is received.

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origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation,

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