CACFP ENROLLMENT FORM

Part 5. Signature (Adult must sign) An adult household member must sign and date this form. I certify that all information on this form is true and correct. I understand that the center will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.
Parent/Guardian Name *
Sign here *

Clear
Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *

Area Code Phone Number
Part 6. Participant's ethnic and racial identities (optional)

Hispanic or Latino Not Hispanic or Latino Asian Black/African American American Indian/Alaska Native White Native Hawaiian/Other Pacific Islander

Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign)

An adult household member must sign this form. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the next page

I certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.
Sign *

Clear
Print name
Date

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Last four digits of Social Security Number *
If none, put NA and check box below
I do not have a Social Security Number

I do not have a Social Security Number

Part 6: Participant's ethnic and racial identities (optional)

Mark one or more racial identities:
Mark one ethnic identity:

Hispanic or Latino Not Hispanic or Latino Not Hispanic or Latino:
Mark one or more racial identities

Asian White Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
The above information may be disclosed for the purpose of enrolling children in the Children’s Health Insurance Program CHIP Parents/guardians are not required to consent to such disclosure and electing not to allow disclosure will not adversely affect a child’s eligibility.

I do elect to allow my household information to be disclosed. I do not elect to allow my household information to be disclosed.
Should be Empty:

Child 1