2025-2026 CACFP Site Application and Memorandum of Understanding

2025-2026 CACFP Site Application and Memorandum of Understanding

Application to participate in the J.A. Henry YMCA Childhood Food Program for the 2025-2026 school year
Site Information
Site Name: (example: Red Bank High School)*
Organization Name: (example: Hamilton County Schools)*
Site-Program Address (full address where meals will be eaten):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (only if different from program address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact*

First NameLast Name
Primary Contact Date of Birth*

MonthDayYear
(required by the state of TN to verify 18+)
Primary Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email Address*
example@example.com
Secondary Program Contact*

First NameLast Name
Secondary Contact Date of Birth*

MonthDayYear
(Required by state of TN to verify 18+)
Secondary Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Email Address*
example@example.com
Organization Type (ex: school, faith based, community, library)*
Does your organization have a website:*

YesNo
If yes, please provide your organizations web address:*
How many years has your organization operated an after school program?*
Does your organization participate in the USDA-sponsored SFSP (summer meals) program during the summer?*

YesNo
What is the age range of the youth in your program?*
Please describe your after school activities:*
Site Eligibility
Are you located in an active school building?*

YesNo
If yes, please provide the state license capacity number:*
Does your program site have access to a functioning restroom with a sink for handwashing?*

YesNo
What is the name of the closest public elementary school to your site?*
Has this institution ever been identified through its corporate organization, officers, employees, or otherwise, as seriously deficient in any Federal or State child nutrition program?*

YesNo
If yes, please explain:*
Is your program open to all children despite race, color, national origin, sex, age, or disability? (A common example of a program not open to all would be a program that is "girls only" or "boys only".)*

YesNo
If no, please explain:*
Site Operation Information
What is your first date of meal service for this school year?*

MonthDayYear
Date
What is your last date of meal service this school year?*

MonthDayYear
Date
What is your average number of participants (what you expect daily)?*
What is your maximum number of participants (program max capacity)?*
What time does your facility open?*

Hour Minutes

AM/PM Option
What time does your facility close?*

Hour Minutes

AM/PM Option
What time will your program open/begin?*

Hour Minutes

AM/PM Option
What time will your program close/end?*

Hour Minutes

AM/PM Option
List any known days or weeks of closing (such as holiday breaks, school breaks):*
If not, type "none" or "n/a"
What are your days of operation?*

MondayTuesdayWednesdayThursdayFridaySaturday
The YMCA's Mobile Fit program sends staff on a limited number of days each week to provide fitness and enrichment activities to the youth in your program. Would you be interested in this program?*

Yes - please send more informationNo
If yes, what day would you be interested in having our staff on site? (check all that would work for your program)*

MondayTuesdayWednesdayThursdayFriday
What meals are you planning to serve (must choose one):*

SupperSupper + Snack (program must be 3 hours or more long to qualify)
What time will your supper meal start serving?*

Hour Minutes

AM/PM Option
What time will your supper meal stop serving (you can have up to a 2 hour meal window)?*

Hour Minutes

AM/PM Option
What time will your snack start serving? (There must be at least a 1 hour gap between supper and snack meal times.)*

Hour Minutes

AM/PM Option
What time will your snack stop serving?*

Hour Minutes

AM/PM Option
Site Procedures
Please describe where your meals will be served at your location?*
Is the site serving meals outside?*

YesNo
If yes, what are the alternate arrangements in case of inclement weather?*
Does your site have a refrigeration unit that can accommodate the number of meals you would like to serve?*

YesNo
If yes, please describe the type of refrigeration unit you have (ex: household unit, commercial 2-door unit, walk-in, etc.)*
Does your site have adequate tables and seating to accommodate the number of children your site expects to serve?*

YesNo
Does your site have adequate adults staff and/or volunteers to accommodate the number of children your site expects to serve?*

YesNo
If yes, how many?*
If no, please explain:*
CACFP and YMCA Guidelines

Below are the program guidelines and responsibilities. It is your responsibility to read and understand these and ensure your site will be able to meet the program requirements.
- Your site is required to have a minimum of two (2) site staff on site for each meal service. These staff must attend a mandatory USDA CACFP training held by the YMCA and complete the provided basic food handler training before the start of your meal service. Sites serving 50+ children will be required to have at least four (4) representatives attend.
- Communicate any turnover in trained staff and update the YMCA when new staff are hired to ensure they complete the appropriate training.
- Meals will be served on site per the USDA.
- Site will accept, inspect, store, and serve food using safe food handling practices.
- Site will serve all components of the meal to children and only at the scheduled meal time and approved location.
- Site will maintain records for every meal service that will include number of meals received, temperature of meals at time of arrival, and number of meals served.
- Site will provide meal orders to the YMCA on a daily basis using the method provided at training.
- Site will maintain program folder provided by the YMCA with copies of meal count forms, signed delivery tickets, attendance records, enrollment records, and temperature logs.
- Site will turn in all completed meal count forms, signed delivery tickets, daily attendance records, and any other required paperwork in a timely manner. You understand that delayed paperwork might result in being billed for the meals received.
- Site will notify the YMCA of any planned program changes or closures at least 1 week in advance.
- Site will ensure that all children have equal access to meals.
- Site will agree to implement and uphold YMCA Health Eating and Physical Activity standards at their site (This is applicable at YMCA and YMCA Mobile Fit supported sites.)
Upload a copy of your annual Chattanooga Fire Department Fire & Life Safety Inspection Report (or your site's local Fire Department).

This document is required by the state for all sites NOT operating an active school location. If you are operating in an active school building, you may skip this step.
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Upload a copy of your enrollment roster

If you do not have this roster completed yet, you can submit it to us via email prior to your first meal service.
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By signing this application, you are declaring that you are the contact for the above listed location and agree to uphold the goals, standards, and initatitives of the YMCA's USDA food service program. You ensure that all agency staff, program volunteers and/or site supervisors will be trained according to the YMCA and USDA program guidelines. You understand that the YMCA will monitor your site program regularlly to ensure program compliance. You understand that if the USDA departemental monitoring reveals repeated deficiencies, the program will be subject to closure.
Signature*
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at:https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11 28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation.

This institution is an equal opportunity provider.

For questions, contact Sam Kamely, Program Director at skamely@ymcachattanooga.org or 423-468-1456.
Would you like to receive a copy of your submission?*

YesNo
Email*
example@example.com
Should be Empty:

2025-2026 CACFP Site Application and Memorandum of Understanding

Site Information

Site Eligibility

Site Operation Information

Site Procedures

CACFP and YMCA Guidelines