CACFP Meal Enrollment Form
Child's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
I work multiple shifts and my child(ren) may be in care on different days/hours
Yes
No
Child #2
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
I work multiple shifts and my child(ren) may be in care on different days/hours
Yes
No
Child #3
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
I work multiple shifts and my child(ren) may be in care on different days/hours
Yes
No
Section 5
Please answer both questions. This information is voluntary.
A. Ethnic data of child(ren) - Mark only one
Hispanic or Latino
Not Hispanic or Latino
Racial data of child(ren) Mark one or more that apply
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Alaskan Indian or Alaska Native
Signature
*
Date
-
Month
-
Day
Year
Date
Telephone Number
*
Continue
Continue
Should be Empty: