Child and Adult Care Food Program ENROLLMENT FORM

Child and Adult Care Food Program ENROLLMENT FORM
Part I - Children's Information
Child's Name*

First NameLast Name
Child's Birthdate*

MonthDayYear
Date
Please Check the Days and Times you Normally need Care

Northside learning center is open Monday-Friday
Please check the days you normally need care:*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
From the hours ofblanks* am to blankpm.
Meals Normally Received
Northside Learning Center Provides Breakfast, Lunch and Afternoon Snack M-F*

I understand
PART 2 - CHILDREN'S ETHNIC AND RACIAL IDENTITIES- You Are Not Required to Answer This Part.
Ethnicity

Hispanic or LatinoNot Hispanic or Latino
Race:

Check the ethnic and racial category of your child. We need this information to be sure that everyone receives benefits on a fair basis. No child will be discriminated against because of race, color, national origin, sex. age. or disability.
Check the box that applies:

WhiteBlack or African AmericanAsianAmerican Indian or Alaskan NativeNative Hawaiianor Pacific IslanderMulti-Racial
Signature of Adult*

Clear
Date*

MonthDayYear
Date
Print Name of Adult Signing*
Your Address*

Mailing Address

Street Address Line 2

City/State/Zip CodeState / Province

Postal / Zip Code
Daytime Phone*
FORM SPI CACFP 1269EF (Rev. 06/16)
Should be Empty:

Part I - Children's Information