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 Name
Site Contact Person
Site Contact Information
Licensed Capacity (attach any supporting docs from licensing division below)
New Site Address
Date Location Changed
/
Month
/
Day
Year
Date
New Site Name
New Site Contact Person
New Phone Number
Format: (000) 000-0000.
New Phone Number Extension
Format: (000) 000-0000.
New Fax Number
Format: (000) 000-0000.
New Site Email Address
example@example.com
New Site Capacity
Rows
Capacity @ 35 Sq. Feet
Capacity @ 25 sq. feet
Licensed Capacity
Change Operating Months, Hours, Days
Months of Operation
Hours of Operation
Days of Operation
New Months of Operation
Rows
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Claim Month Effective
Check ALL that apply
New Hours of Operation
Rows
Open
Close
Claim Month Effective
Center Hours
New Days of Operation
Rows
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Claim Month Effective
Check ALL that apply
Meal Type Change
Rows
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.
Title
Date
/
Month
/
Day
Year
Date
E
mail
:
info@yeskidz.com
Fax #: (
770) 938-
6869
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