BCDC 2022 - 2023 CACFP Enrollment Forms

CACFP STUDENT ENROLLMENT FORM
Which location will your child(ren) attend?*
Burleson Child Development Center 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 or guardians to annually review and make changes to enrollment data.
How many children are you enrolling at BCDC?*
If more than 3 you will need to complete this form a second time.
CHILD(REN) INFORMATION
1. Center Enroll Date

MonthDayYear
Date
1. Child's First Name
1. Child's Last Name
1. Child's Date of Birth

MonthDayYear
Date
Hispanic or LatinoNot Hispanic or Latino
WhiteBlack / African AmericanAsianAmerican Indian / AlaskanNative Hawaiian / Other
FemaleMale
MondayTuesdayWednesdayThursdayFriday
1. Normal Arrival Time
1. Normal Departure Time
BreakfastLunchAfternoon SnackSchool Age Supper
2. Center Enroll Date

MonthDayYear
Date
2. Child's First Name
2. Child's Last Name
2. Child's Date of Birth

MonthDayYear
Date
Hispanic or LatinoNot Hispanic or Latino
WhiteBlack / African AmericanAsianAmerican Indian / AlaskanNative Hawaiian / Other
FemaleMale
MondayTuesdayWednesdayThursdayFriday
Normal Arrival Time
Normal Departure Time
BreakfastLunchAfternoon SnackSchool Age Supper
3. Center Enroll Date

MonthDayYear
Date
3. Child's First Name
3. Child's Last Name
3. Child's Date of Birth

MonthDayYear
Date
Hispanic or LatinoNot Hispanic or Latino
WhiteBlack / African AmericanAsianAmerican Indian / AlaskanNative Hawaiian / Other
FemaleMale
MondayTuesdayWednesdayThursdayFriday
Normal Arrival Time
Normal Departure Time
BreakfastLunchAfternoon SnackSchool Age Supper
PARENT / GUARDIAN INFORMATION
I certify the information on this form is true and correct to the best of my knowledge and that I have received access to WIC and CACFP literature within the last 12 months.
Parent's First Name*
Parent's Last Name*
Cell Phone
Signature

Clear
Date

MonthDayYear
Date
Non - Discrimination 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 identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint 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 your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)
Please reference the chart below, does your household income fall below the amounts listed?
Part 1. All Household Members
How many members are in your household (including children)?*
1. Household Member Name*
Yes, enrolled at center
Check if a foster child (the legal responsibility of a welfare agency or court)Check if this person has no income.
2. Household Member Name*
Yes, enrolled at center
Check if a foster child (the legal responsibility of a welfare agency or court)Check if this person has no income.
3. Household Member Name*
Yes, enrolled at center
Check if a foster child (the legal responsibility of a welfare agency or court)Check if this person has no income.
4. Household Member Name*
Yes, enrolled at center
Check if a foster child (the legal responsibility of a welfare agency or court)Check if this person has no income.
5. Household Member Name*
Yes, enrolled at center
Check if a foster child (the legal responsibility of a welfare agency or court)Check if this person has no income.
6. Household Member Name*
Yes, enrolled at center
Check if a foster child (the legal responsibility of a welfare agency or court)Check if this person has no income.
7. Household Member Name*
Yes, enrolled at center
Check if a foster child (the legal responsibility of a welfare agency or court)Check if this person has no income.
Part 2. Benefits: If any member of your household receives SNAP, TANF, or FDPIR, provide the name and case number for the person who receives benefits. If no one receives these benefits, skip to part 3.
Does anyone in the household receive SNAP, TANF or FDPIR?*
NAME:*
ELIGIBILITY / CASE NUMBER:*
*SNAP or TANF numb er must be the 8 or 9 digit EDG# assigned by HHSC
Part 4. Total Household Gross Income—You must tell us how much and how often

B. Gross income and how often it was received
How many household members have income?*
1. Name of household member that has income*
1a. Earnings from work before deductions (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
1b. Do you receive welfare, child support or alimony?*
1b. Amount from welfare, child support or alimony (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
1c. Do you receive pensions, retirement, Social Security, SSI, or VA benefits?*
1c. Amount from pensions, retirement, Social Security, SSI or VA benefits (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
1d. Do you receive any other type of income?*
1d. Amount from other type of income (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
2. Name of household member that has income*
2a. Earnings from work before deductions (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
2b. Do you receive welfare, child support or alimony?*
2b. Amount from welfare, child support or alimony (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
2c. Do you receive pensions, retirement, Social Security, SSI, or VA benefits?*
2c. Amount from pensions, retirement, Social Security, SSI or VA benefits (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
2d. Do you receive any other type of income?*
2d. Amount from other type of income (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
3. Name of household member that has income*
3a. Earnings from work before deductions (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
3b. Do you receive welfare, child support or alimony?*
3b. Amount from welfare, child support or alimony (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
3c. Do you receive pensions, retirement, Social Security, SSI, or VA benefits?*
3c. Amount from pensions, retirement, Social Security, SSI or VA benefits (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
3d. Do you receive any other type of income?*
3d. Amount from other type of income (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
4. Name of household member that has income*
4a. Earnings from work before deductions (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
4b. Do you receive welfare, child support or alimony?*
4b. Amount from welfare, child support or alimony (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
4c. Do you receive pensions, retirement, Social Security, SSI, or VA benefits?*
4c. Amount from pensions, retirement, Social Security, SSI or VA benefits (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
4d. Do you receive any other type of income?*
4d. Amount from other type of income (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
5. Name of household member that has income*
5a. Earnings from work before deductions (dollar amount) *
5a. How often are you paid this amount?*
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
5b. Do you receive welfare, child support or alimony?*
5b. Amount from welfare, child support or alimony (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
5c. Do you receive pensions, retirement, Social Security, SSI, or VA benefits?*
5c. Amount from pensions, retirement, Social Security, SSI or VA benefits (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
5d. Do you receive any other type of income?*
5d. Amount from other type of income (dollar amount) *
WeeklyEvery 2 weeks2x MonthlyMonthlyAnnually
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 here:*

Clear
Print name:*
Date:*

MonthDayYear
Date
Address:*
City:*
State:*
Zip Code:*
Phone Number:*
Last four digits of Social Security Number:
I do not have a Social Security Number
Part 6. Participant's ethnic and racial identities (optional)
Hispanic or LatinoNot Hispanic or Latino
AsianAmerican Indian or Alaska Native NativeWhiteHawaiian or Other Pacific IslanderBlack or African American
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: