New York State Department Of Health Cacfp Enrollment Form
ADVERTISEMENT
1ENROLLMENT DATE: __
'__
'__
CACFP Agreement # 4956
Provider#
_
~CACFP
~
Child and
Adult Care
Food Program
New
York
State Departmentof
Heallh
CHILD ENROLLMENT FORM
for Day Care Homes
Parent or Guardian completes form
Name
of Day
Care or Owner/Operator
On-Site
Provider
(if
different)
Child's
Name
Child
#
DOB
o
Male
o
Female
Child's Name
Child
#
DOB
o
Male
o
Female
Child(ren)'s
Ethnic Information
(Chooseone optionper child)
Child(ren)'s
Racial Information
(Choose one optionper child)
o
Hispanic or Latino
o
American Indian or Alaskan
Native
o
Asian
o
Not
Hispanic
or
Latino
o
Native Hawaiian or other
Pacific
Islander
o
White
o
Black or
African American
Primary
language spoken at home
Check
if
any
of these
apply
o
Resident Child
o
Child
is
related
to
Provider
o
Child of Migrant Farm Worker
o
Special
Needs
o
Foster Child
HOURS/DAYSIMEALS
Time Care Begins
Time Care Ends
Days child normally
receives
care
o
Mon-Fri
OR
OMon
o
Tues
OWed
o
Thurs
o
Fri
o
Sat
o
Sun
Meals Child
normally
receives in care
o
Breakfast
o
AM
Snack
0
Lunch
o
PM Snack
o
Supper
o
LN
Snack
Holiday
and/or
Weekend
Care
DYes
ONo
Time Care
Begins
___
Time Care
Ends
___
Does
child(ren)
attend school
DYes
DNa
Name of School
Does
child receive care on non-school
days?
DYes
ONo
INFANT FEEDING STATEMENT
(must be completed for any child less than one year of age)
o
The Parent will supply breastmilk or formula
o
The
Parent will supply ALL
infant's
food
o
The
Provider will
supply formula
o
The
Provider will
supply
infant's food
CONTACT INFORMATION
FOR PARENT/GUARDIAN
Parent/Guardian's
Name
Home Address
Home Phone Number
Work/Cell
Phone Number
Parent/Guardian
Signature
Date
Sponsor Use Only Section
Date
Enrollment Begins
Date Enrollment
Expires
ChildEnrollment Approved
(initials)
-
Emergency
Placement
-
(Provider
NOllie)
..
In accordance with Federal
Law
and USDepartment
of
Agriculture
policy,
this institution ISprohibited from
dtscnmmatlng on
the
baSIS
of
race,
color,
national
Origin,
sex, age,
or
disability.
To
file a complaint of
discrimination,
write
USDA,Director, Office of
Adjudication,
1400
Independence
Avenue, SW,
Washington,
DC20250- 9410 or call toll free (866) 653-9992
(Voice).
Individuals who
are hearing impaired
or
have speech
disabilities may
contact USDAthrough the
Federal
RelayService at
(800)
877-8339 or (800) 845·6136
(Spanish).
USDA
is
an equal
opportunity
provider and
employer.
DOH-4419 (3/12)
White (Sponsor) Yellow (Provider)
PAGE 1 OF 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Emedny-490301 - Application For Enrollment As A Specialist Form - New York State Department Of Health
Legal
Form Doh-3667 - Application To Department Of Health For Copy Of Fetal Death Record - New York State Department Of Health Vital Records Section
Legal
Form Doh-348 Application For Approval Of Plans For Public Water Supply Improvement - New York State Department Of Health
Legal
Form Doh-4334 - Methadone Usage Summary Report - Bureau Of Narcotic Enforcement Of New York State Department Of Health
Legal
Related Categories
Parent category: Education