Site Change Notification Form

Site Change Notification Form

CACFP Food Program
Site Name
Address
Place a check only in the boxes that require an update to the application and enter the new information in the space provided. You may be required to submit supporting documentation for the change. Items not listed on this form do not need to be updated in the application until a renewal application is submitted.

Site Address (attach updated DECAL license below)Site NameSite Contact PersonSite Contact InformationLicensed Capacity (attach any supporting docs from licensing division below)
New Site Address
Date Location Changed

MonthDayYear
Date
New Site Name
New Site Contact Person
New Phone Number
New Phone Number Extension
New Fax Number
New Site Email Address
example@example.com

New Site Capacity

	Capacity @ 35 Sq. Feet	Capacity @ 25 sq. feet
Licensed Capacity

Change Operating Months, Hours, Days

Months of OperationHours of OperationDays of Operation

New Months of Operation

	Jan	Feb	Mar	Apr	May	Jun	Jul	Aug	Sept	Oct	Nov	Dec	Claim Month Effective
Check ALL that apply

New Hours of Operation

	Open	Close	Claim Month Effective
Center Hours

New Days of Operation

	Mon	Tue	Wed	Thu	Fri	Sat	Sun	Claim Month Effective
Check ALL that apply

Meal Type Change

	Select ALL Meals to be Changed	Meal Time Begins	Meal Time Ends	Claim Month Effective
Breakfast
Lunch
AM Snack
PM Snack
Supper

I certify that I am authorized to make this request to YES Inc. and that the information I have provided above is true and correct.

Clear
Title
Date

MonthDayYear
Date
Email: info@yeskidz.com Fax #: (770) 938-6869
Should be Empty: