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  • Dear Parent/Guardian:


    This center offers healthy meals to all enrolled children as part of our participation in the U.S. Department of Agriculture’s (USDA) Child and Adult Care Food Program (CACFP). The CACFP provides reimbursements for healthy meals and snacks served to children enrolled in child care. Please help us comply with the requirements of the CACFP by completing the attached Food Program Enrollment Packet, which includes Food Program Enrollment Form & Meal Benefit Income Eligibility Form.

  • Format: (000) 000-0000.

  • Enrolled Child 1 Details

    Let's begin by answering the enrollment questions below for your first child currently enrolled at this daycare.
  • 1b – Date of Birth*
     - -
  • 1c – Enrollment Date*
     - -
  • 1d – Days in Care*
  • 1g - Meals Served While in Care*
  • 1h - Ethnicity*
  • 1i - Race*
  • 1h - Do you have any additional children enrolled at this daycare?*

  • Enrolled Child 2 Details

    Now, answer the enrollment questions below for your second child currently enrolled at this daycare.
  • 2b – Date of Birth*
     - -
  • 2c – Enrollment Date*
     - -
  • 2d – Days in Care*
  • 2g - Meals Served While in Care*
  • 2h - Ethnicity*
  • 2i - Race*
  • 2h - Do you have any additional children enrolled at this day care?*

  • Enrolled Child 3 Details

    Time for enrollment questions regarding your third child currently enrolled at this daycare.
  • 3b – Date of Birth*
     - -
  • 3c – Enrollment Date*
     - -
  • 3d - Days in Care*
  • 3g – Meals Served to Child While in Care*
  • 3h - Ethnicity*
  • 3i - Race*
  • 3h - Do you have any additonal children enrolled at this daycare?*

  • Enrolled Child 4 Details

  • 4b – Date of Birth*
     - -
  • 4c – Enrollment Date*
     - -
  • 4d – Days in Care*
  • 4g - Meals Served While in Care*
  • 4h - Ethnicity*
  • 3i - Race*

  • CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (CHILD CARE)

  • Part I. Household Members


    List ALL household member names below, including yourself & the enrolled child(ren) you included on previous page(s). Also, next to each name be sure to check each box that applies. 

  • Rows

  • ________________________________

    Part II. Benefits

    If any member of your household receives SNAP, TANF, or FDPIR, provide the name and eligibility number for the person who receives benefits.

  • Does anyone is the household receive SNAP, TANIF, or FDPIR?*

  • ________________________________

    Part IV. Household Income

    If any member of your household receives income, please provide the name of the person receiving income, gross amount, and how often it is received. EVEN IF you feel your household income level will not qualify for the highest program benefits, please still provide it as our facility does receive some assistance, even for higher-income households. The CACFP helps reduce our costs for providing your child with the best nutrition possible. And, of course, your information is always kept 100% confidential.

  • Does anyone in the household receive income?*

  • ________________________________

    Household Income Details

    List only household members with income. First MI Last Name

    Please provide amount and how often for each household member listed. Hourly Rate is not acceptable. 

  • Rows

  • ________________________________

    Part V. Submitting Party Details 

    Please provide your details as the parent/guardian submitting this food program enrollment packet.

  • Format: (000) 000-0000.

  • Part 5. Signature

    I certify that all information on this form is true and that all income is reported. I understand that the center or daycare 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.

     

    The signature below must match your physical signature as much as possible. 

  • Today's Date*
     - -

  • For Determining Official Use Only

  • Frequency
  • Eligibility
  • Determination Date
     - -
  • Should be Empty: