Center Legal Name
*
Center Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Center E-mail
*
example@example.com
Center Phone Number
*
Please enter a valid phone number.
Extension
Center Fax Number
Please enter a valid phone number.
Point of Contact Responsible for On-Site Daily Food Operations
Salutation
*
Please Select
Mr
Mrs
Ms
Miss
Dr
Name
*
First Name
Last Name
(POC) Point of Contact Title
*
POC Date of Birth
*
-
Month
-
Day
Year
Date
POC Phone Number
*
Please enter a valid phone number.
POC Fax Number
Please enter a valid phone number.
POC Cell Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Do you have Shareholders or a Board of Directors?
*
Yes
No
Name of President/Board Chairman/Owner?
*
First Name
Last Name
Owner Date of Birth
*
-
Month
-
Day
Year
Date
Owner Cell Telephone Number
Please enter a valid phone number.
What type of Center are you operating? Select only one type.
*
For Profit
Private Non-Profit with Current 501(c)(3)
Church (Private non-profit)
Public (administered by a municipality, county, state, or federal agency (e.g., Head Start Agencies)
Upload Center Childcare License
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Upload DCF Inspection report
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Upload Current attendance roster
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If non-profit, upload current 501(c)(3) Tax Exempt Status Certificate
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Upload Statement of Authority if non-profit is utilizing the 501 (c) 3 of a parent organization.
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If not licensed (Religious-exempt) submit copy of Religious Exempt Accreditation Certificate
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of
If not licensed (Religious-exempt) submit copies oFire Marshal Inspection Report/Permit
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of
If not licensed (Religious-exempt) submit copies of Occupancy Permit
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of
Do you currently provide meals to your children?
*
Yes
No
If so, do you charge for meals served?
Yes
No
Do you currently participate in the CCFP program?
*
Yes
No
If so, Are you....
Directly with State
Under Sponsorship
Have you ever been on the CCFP Program?
*
Yes
No
If so, what is the date of last claim filed?
-
Month
-
Day
Year
Date
Was it filed directly with state or under sponsorship?
Directly with State
Under Sponsorship
Does center accept all children regardless of race, color, age, sex, disability and national origin?
*
Yes
No
# of Birth to 11 Months Enrolled
# of 1-2 yr. olds Enrolled
# of 3-5 yr. olds Enrolled
# of 6-12 yr. olds Enrolled
# of Disabled (over 12 yrs. old) Enrolled
# of Migrant (Birth to 15 yrs. old) Enrolled
Total Enrolled
Number of children by Ethnicity:
Hispanic / Latino
Non-Hispanic / Latino
Number of Children by Race
American Indian/Alaskan Native
White
Black/African American
Asian
Native Hawaiian/other Pacific Islander
Does center receive any Head Start or Early Head Start Funding?
*
Yes
No
# of children enrolled in School Readiness?
Agency providing School Readiness?
Please Select
Early Learning Coalition of Hillsborough County
Early Learning Coalition of Manatee County
Early Learning Coalition of Pasco County
Early Learning Coalition of Pinellas County
Early Learning Coalition of Polk County
Type of licensing, choose 1 only.
Licensed by DCF or county child care licensing agency.
Religious Exempt
Military Child Care (Department of Defense Certificate to Operate)
Public or Private school (not required to have state or county child care license)
I understand that Cornerstone Family Ministries is a Sponsor of the Child Care Food Program (CCFP) through the Florida Department of Health (state agency). While Cornerstone Family Ministries sponsorship of the program is designed to help centers like mine to benefit from the program without the liability of a direct contract with the State, I do understand that I can choose to apply directly with the state agency and incur that liability on my own.
*
I understand
EIN Number
Center hours of Operation - OPEN / CLOSE
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Days of Week (Select all that apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Will there be any months you will NOT operate the Child Care Food Program?
*
Yes
No
Breakfast Start / End Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Lunch Start / End Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
PM Snack Start / End Time
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Will meals be claimed over licensed/approved capacity?
*
Yes
No
If you are approved to provide the CCFP, what method of Meal Service will you provide, choose 1 only.
*
Center Prepares meals on-site
Limited Prep
Catered
Center has 3 compartment sink?
*
Yes
No
Center has dishwasher
*
Yes
No
Acknowledgement of How Program Funding Works: I understand that if approved to participate in the Child Care Food Program through Cornerstone Family Ministries (CFM) that I will be sub-contracting with CFM who is s Sponsor of the USDA Child Care Food Program through the Florida Department of health (FLDOH). As my sponsor, Cornerstone Family Ministries recruits, qualifies, monitors and administers the CCFP program and files a collective claim for all of it's 140+ sponsored centers monthly. Cornerstone disburses from their claim a reimbursement for up to two meals and one snack or two snacks and one meal per child, per day to centers under their sponsorship. Monthly payment are based on the nu ber of children served, the financial qualification of those children, and the number of compliant meals served. Even though this program is not a cost reimbursement program, I will be required to provide evidence of my costs each month so that Cornerstone cand insure to the FLDOH that the dollars they disburse to their sub-contracted centers do not exceed expenses for the program. The amount CFM receives for each meal served and disburses to its center partners is set by the FLDOH and the USDA periodically and is available through this link: USDA Reimbursement Rates https://www.fns.usda.gov/sfsp/fr-011924. I understand that in order to be included in Cornerstone's monthly claims my center must have 25% or more School Readiness (Title XX) and/or free and reduced qualified children enrolled. Finally, I understand that if approved, I must collect meal application forms or enrollment participation forms for each child in my center before my first claim is filed.
*
I understand
Does this center or either responsible individual on the application appear on the Florida Disqualified List or the National Disqualified list?
*
Yes
No
Does the previously collected license inspection report or the food service inspection/permit certification indicate compliance or a satisfactory rating for the food service operation?
*
Yes
No
Comments or Notes
Submitted Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: