As an Ezion Fair Community Academy parent, I have met with the Academy's Director and reviewed the Ezion Fair Community Academy's Parent Handbook. I agree to:

Above all, EFCA reserves the right to maintain a harmonious and safe environment for the children; our goal is to bring about collaboration between the home and school in ways that enhance your child's development.

Are there any recent traumatic situations the child has been exposed to such as: (death in the family, divorce, new siblings etc.? If yes, please describe:

How is your child easily settled when upset or afraid? Are there any other comments or information you would like to let us know about?

ANY LICENSED CHILD CARE FACILITY. TO REVIEW A CHILD CARE FACILITY RECORD CONTACT: Ms. Ann Marie

Bercy, Office of Child Care Licensing, 3411 SILVERSIDE ROAD, CONCORD PLAZA I HAGLEY BUILDING,

WILMINGTON, DELAWARE 19810-4803.

You may also view substantiated complaints and compliance review histories for the past three years by visiting http://www.apex01.kids.delaware.gov:7777/occl/

I acknowledge I received this notice as part of the application packet.

Children may have an educational movie or program incorporated into their curriculum. Movies shown will be age appropriate and not exceed one hour in length.

I hereby authorize my child to watch educational movies.

Children, over the age of 2 years old, will have the opportunity to occasionally play educational games on the computer. Children will be closely supervised to ensure that age-appropriate and educational websites are being viewed while using the internet. Computer time will not exceed one hour in length.

I hereby authorize my child to use the computer.

I certify that I have received information regarding the following topics: a typical daily schedule, positive behavior management techniques, routine and emergency health care, health exclusions, and prevention of communicable diseases, food and nutrition, procedures for releasing children, reporting of accidents, injuries or critical incidents, mandatory reporting of child abuse and neglect, administration of medication procedures, safe sleep procedures for infants, pets or animals present in the home regardless of the location within the Family Child Care Home and transportation, if provided.

TRANSPORTATION PERMISSION I hereby give permission for my child to be transported by

Delaware Department of Education Child Nutrition Programs Office Child and Adult Care Food Program (CACFP)

PART 1 (This part must be completed for all participants. Enter the participant(s) name and information

Hispanic/Latino (Choose one ethnicity-Required for statistical reporting)

Native Hawaiian/ American Indian/ Alaskan Native (Choose one or more regardless of ethnicity - Required for Statistical reporting)

Hispanic/Latino (Choose one ethnicity-Required for statistical reporting)

Native Hawaiian/ American Indian/ Alaskan Native (Choose one or more regardless of ethnicity - Required for Statistical reporting)

Normal days of week Participant(s) is/are in care (circle all that apply):

Meals eaten at Providers/Center: (Circle all that apply. CACFP provides reimbursement for up to 2 approved meals and one snack per day/participant): BreakfastXAM SnackLunchXPM SmackxEvening Snack Supper

List Names of All Household Members (Attach Any Additional Members)

(Please indicate by income as weekly, bi-weekly, 2x's a month, monthly or yearly) Earnings from WorkWelfare, Child Support,Payments from (Before Deductions)Alimonyany Other Income Job 1 Social Security $ 200/weekly$ 150/twice a month$ 100/monthly

4 5 6 PART 3 - SIGNATURE and LAST FOUR OF SOCIAL SECURITY NUMBER An adult household member must sign and date this form before it can be approved. If Part 2D is completed, the adult signing the form must also list thelast 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 back of this page PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct, that the SNAP or TANF Number is correct, and that all income is reported. I understand that this information is being given for the receipt of Federal funds; that institution officials may verify the information on the statement, and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws.

Last four digits of Social Security Number:

ELIGIBILITY - Based on the information provided this application will be: Approved FREE Approved REDUCED Determining Official Signature:

Equal Opportunity Provider and Employer

Instructions for Completing the Child and Adult Care Food Program (CACFP) Income Eligibility Form (Child Care)

PART 1: PARTICIPANT'S INFORMATION: ALL HOUSEHOLDS COMPLETE THIS PART.

(1) Print the name or names of the Participant(s) enrolled. (2) RACIAL/ETHNIC IDENTITY: COMPLETE THE RACIAL/ETHNIC IDENTITY. You are not required to answer this question to get meal benefits. This information will help ensure that everyone is treated fairly. (3) Start date, arrival and departure times, normal days and normal meals must be completed at the time of enrollment and/or renewal.

(1) List your current SNAP Case Number or your TANF Identification Number for the participant. DO NOT complete Part 2B, 2C or 2D. (2) An adult household member must sign the form in Part 3. PART 2B: ONLY HOUSEHOLDS ENROLLING A FOSTER CHILD: COMPLETE THIS PART AND PART 3. Refer to specific instructions indicated. List all foster children. Check the box indicating that the child is a foster child.

PART 2A: ONLY HOUSEHOLDS GETTING SNAP OR TANF BENEFITS: COMPLETE THIS PART AND PART 3.

(1) Write the names of everyone in your household. (2) Write the amount of income received last month for each household member (the amount before taxes or before anything else is taken out), and where it came from, such as earnings, welfare, pensions, and other income (refer to examples below for types of income to report If any amount last month was more or less than usual, write that person's usual income. An adult household member reporting total household income must sign the form and include the last four digits of give his/her Social Security Number in PART 3. Note to Center/Reviewer: If you are uncertain of how the family receives income (monthly, weekly, bl-weekly, annually) consider the income reported as the income for the month. If this is not workable, contact the family for clarification.

PART 2C: HOMELESS ENROLLEES ONLY. CHECK THE BOX AND COMPLETE PART 3. PART 2D: ANY HOUSEHOLD REPORTING TOTAL HOUSEHOLD INCOME. COMPLETE THIS PART AND PART 3.

Earnings From Employment: Wages/Salaries/Tips Strike Benefits Unemployment Compensation Worker's Compensation Net income from self-owned business or farm Welfare/Child Support/Alimony:

Public Assistance Payments Wellare Payments Alimony/Child Suppon

Pensions/Retirement/Social Security: Pensions, Supplemental Security Income Cash withdrawn from savings, Retirement Income Veteran's Payments Social Security Regular contributions from persons not living in the household Military Houschold: All cash income, including military housing uniform allowances Does not include in-kind" benefits NOT paid in cash (base housing, medical care, clothing, food, etc

Other Income: Disability Benefits Interest/Dividends Income from Estate/Trusts/lovestments Net Royahties/Assuities Net Rental Income Any Other Income Foster Child's Income: ONLY funds from welfare agency identified by category for personal use of child (clothing, school fees, etc, funds from child's family for personal use, and earnings from other sources (i.e., occasional or part-time employment) need to be included. DO NOT count funds from welfare agency for sheher, care, etc.

(1) All Income Eligibility Forms must have the signature of an adult household member. (2) The adult household member who signs the form must include the last four digits of his/her Social Security Number IF the participant is cligible for "free or reduced" based on household income. Section 9 of the National School Lunch Act requires that unless the participant's SNAP (food stamp), TANF case number is provided or the participant is a foster child or homeless, you must include the last four digits of the Social Security Number of the household member signing the statement, or an indication that the household member signing the statement does not possess a Social Security Number. Provision of the last 4 digits of the Social Security Number is not mandatory, but if a Social Security Number is not provided or an indication is not made that the adult household member signing the statement does not have one, the statement cannot be approved. The Social Security Number may be used to identify the household member in carrying out efforts to verify the correctness of information stated on the statement. These verification efforts may be carried out through program reviews, audits, and investigations and may include contacting employers to determine income, contacting a SNAP or TANF office to determine current certification for receipt of SNAP or TANF benefits, contacting the State Employment Security Office to determine the amount of benefits received and checking the documentation produced by the household member to prove the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims or legal action. If he/she does not have a Social Security Number, check the "I do not have a Social Security Number" box. (3)If you listed a SNAP or TANF case number or the participant is a Head Start, ECAP, Foster or Homeless child, the last four digits of a Social Security Number is not needed. SPONSOR USE ONLY - Eligibility Determination: To be completed by Child Care Representatives ONLY. (1) Complete total household income and size section. Compare total Income to Household Income Eligibility Guidelines. When household incomes are listed from different pay persons, you must convert all income to yearly income using the conversion table listed. Follow other instruction as indicated. (2) The review/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. PRIVACY ACT STATEMENT: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve the participant for free or reduced price meals. You must include the last four digits of the Social Security Number of the adult household nember who signs the application The SocialNumberis Securitynot required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP. i.e., Food Stamp Temporary Assistance for Needy Families (TANF) Program or when you indicate that the adult household member signing the application does not have a Social Security Number We will use your information to determine if the participant is eligible for free or reduced price meals, and for administration and enforcement of the Program. NON-DISCRIMIINATIOX STATEMENT: The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identify, religion, reprisal, and where applicable, political belicfs, marital status, familial or parental statis, sexual orientation, or all or of individual'sis orderived from any public assistance program, or protected genetic information in employment or in any or part an income conducted programactivityfunded theall byDepartment(Notprohibitedbaseswill toall apply programsand'or employment activities If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complain Form, found online at http://www.ascr.usda gov/complaint filing_ cust html or at any USDA office. or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form Send completedcomplaintformorlettertousbymailatU.S.ofAgriculure, yourDepartment Director,of Office1400 Adjudication,Avenue,D.C. IndependenceS.W.,20250-9410,690-7442 Washington,by fax (202) or email at program intake@usda gov. Individuals who are deal. hard of hearing. or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish) USD.4 is an equal opportunity provider and employer.

PART 3: CERTIFICATION - SIGNATURE AND SOCIAL SECURITY NUMBER: ALL HOUSEHOLDS COMPLETE THIS PART.

Fair Christian Community Academy 1400 B Street, Wilmington, DE 19801

This child care center participates in the USDA Child and Adult Care Food Program (CACFP) and receives Federal funds to provide healthy meals and snacks to all of the enrolled children. The amount of reimbursement the center receives is based on the information you provide on the attached Household Eligibility Application. Part of the USDA requirement is to ask you to complete the application. If your income is equal to or less than the income listed in the chart below for your household size, the center will receive a higher level of reimbursement. Read the attached instructions carefully and fill out all required information. We cannot approve an application that is not complete. Please return the completed application back to our center as soon as possible. If a member of your family (child or adult) receives Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) benefits; or you care for a foster child that is the legal responsibility of the State through DCFS or the court, these children are eligible for meal benefits regardless of your household income. If your income(s) is over the income guidelines listed below, you are not required to complete this application; however, it would be helpful if you would write your child's name on the application and return it to our center. Please notify us, if you or someone in your household becomes unemployed and the loss of income causes your household income to be within the income eligibility standards. If a member of your family (child or adult) receives Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) benefits; or you care for a foster child that is the legal responsibility of the State through DCFS or the court, these children are eligible for meal benefits regardless of your household income. If your income(s) is over the in

come guidelines listed below, you are not required to complete this application; however, it would be helpful if you would write your child's name on the application and return it to our center. Please notify us, if you or someone in your household becomes unemployed and the loss of income causes your household income to be within the income eligibility standards.

July 1, 2015, Through June 30, 2016 Reduced-Price Meals

21,590 29,101 36,612 44,123 51,634 59,145 66,656 74,167 7,511

1,800 2,246 3,051 3,677 4,303 4,929 5,555 6,181 626

Twice Per Month 900 1,213 1,526 1,839 2,152 2,465 2,778 3,091 313

831 1,120 1,409 1,698 1,986 2,275 2,564 2,853 289

416 560 705 849 993 1,138 1,282 1,427 145

"Making a Difference in Your child's Future - TODAY!1

DELAWARE HEALTH AND SOCIAL SERVICES

Special Supplemental Nutrition Program for Women, Infants & Children (WIC)

Division of Public Health WIC Program

CHILD & ADULT BRANDS LISTED ONLY

All sizes in each variety up to a 36 ounce package is WIC authorized.

General MillsKixGeneral Mills Multi-Grain Kix Cheerlos

Any variety of fresh, bulk fruits and vegetables Bagged fruit and vegetables Bagged salad mixes (without dressing, croutons, nuts or meat added) Tubs of cut fruit or vegetables (without dressing or dip) Organic CANNOT BUY: frozen fruit, frozen vegetables, canned fruit, canned vegetables, dried fruit, dried vegetables, herbs (i.e., basil, cilantro, parsley), spices (i.e., vanilla bean, cinnamon sticks) or fruit cups (i.e., Del Monte, Dole)

Nabisco Cream of Wheat Whole Grain NO Individual

Quaker Instant Oatmeal (regular/original)

The Delaware WIC Program will allow split tender transaction when using the Cash Value Voucher This will permit the WIC Customer to pay the difference for fresh fruit and vegetables if they go over the assigned value of the CVV.

Individual serving packages only

WAYS TO BUY 36 OZ OF CEREAL OR LESS

Milk Store or Store Designated Brand

CANNOT BUY calcium/fiber fortified juice, juice drinks, juice ades, juice beverages, sweetened juices

Contract Brand Rice, oatmeal*, multigrain*, whole wheat* CANNOT BUY organic, DHA or Cereal mixed with fruit *Young infants mily be allergic to these.

Fresh (not flavored) Whole, Reduced Fat (1%), Skim Lactose Reduced (Whole, Reduced Fat (1%), Skim) Evaporated Milk (Whole, Reduced Fat (1% UHT "Ultra High Temperature" (Whole, Reduced Fat (1%), Skim) (example: Parmalat) Soy Milk (8th Continent: Original or Vanilla)

64 OZ. BOTTLED, UNSWEETENED, SINGLE STRENGTH

Juicy Juice All Varleties 100% Julce

Gerber Brand - 2nd Foods 4.0 ounce containers (2 packs) Single or mixed vegetables Fruit & Veggie Blend CANNOT BUY organic, dinners or DHA

CANNOT BUY flavored milk, raw unpasteurized milk, non-dairy milk substitutes, rice milk, organic or almond milk

Gerber Brand - 2nd Foods 4.0 ounce containers (2 packs) Single or mixed fruit Fruit & Veggie Blend CANNOT BUY desserts or medleys, custards or puddings, organic or DHA

Store or Store Designated Brand

Creamy or crunchy, 16 18 oz. jar CANNOT BUY peanut butter spreads, peanut butter with added flavors or fortified peanut butter, natural or organic

Old Orchard All Variatles 100% Julce

Store or Store Designated Brand

Gerber Brand - 2nd Foods CANNOT BUY graduates, sticks, dinners or organic

1 pound package (16 oz Any mature variety CANNOT BUY canned beans or soup mixes (added spices or meat)

Store or Store Designated Brand 1 dozen Large, white only CANNOT BUYbrown, free-range, specialty eggs (Eggland's Best or EggsPlus) or organic

1 pound loaf/package (16 oz 100% Whole Wheat only

Old Orchard All Varleties (must have green tear stripe)

Welch's All Varletles (must have yellow tear stripe)

Store or Store Designated Brand

Pasteurized Process American cheese, cheddar & mozzarella 1 lb. or 16 oz. package only CANNOT BUY8 OZ packages, Velveeta, Cheese Wiz, Kraft Singles, low fat or low sodium products, grated, shredded, cheese sticks, deli-sliced cheese, variety packs (i.e., American/Swiss), imported cheese, cheese food, product or spread, cheese with added flavors, individually wrapped slices or organic

Store or Store Designated Brand Chunk Light, water packed, 5 7.5 OZ. can

Store or Store Designated Brand

Wild Alaska, Pink Salmon, water packed, up to a 7.5 OZ can CANNOT BUY albacore tuna, tuna spreads, or any other type of salmon, lunch packs, or fish with added flavoring, low sodium, diet or ready-to-serve

Call the state WIC Vendor Unit at 1-800-222-2189 or

DELAWARE HEALTH AND SOCIAL SERVICES

Division of Public Health WIC Program

Essential For New Scholars' First Day!

Delaware WIC Program Breastfeeding Help

WIC Breastfeeding Peer Counselor or Coordinator 1-800-222-2189

Free WIC Breastfeeding Clasaes at Your Local Clinic

Hudson State Service Center Call for appointment 302-283-7692

Latin American Community Center Wilmington, DE

Westside Health Center Winington, DE

Call for schedule 302-555-5822 or 302-593-9967

Nursing Mothera Inc. http:hww.nursingmonis.org

MILFORD MEMORIAL HOSPITAL - MILFORD 302-744-7233

"In accordance with Federal law and U.S. Department of Acricuture policy, this Institution is from on te tasis of race, color, national origin, sex, age, or disabity. Totle a complant of discimination, vrite USDA, Cirector, Office of independence Averue, 0.20250-94 10or cal [900] 756-3272 or (900) 877-0339 (TTY USDAIs an equal, apportunty provider and employer,*

DELAWARE HEALTHAND SOCIAL SERVICES

OMISION of Pubile Heelth WIG Program