KD'S Food Program Enrollment Form

KD'S Food Program Enrollment Form
PART 1 – ENROLLMENT INFORMATION

Name(s) of Enrolled Child(ren)
Name of Child 1

First NameLast Name
Date*

MonthDayYear
Date
YesNo
SundayMondayTuesdayWednesdayThursdayFridaySaturday
Input Normal Days of Care*
BreakfastA.M. SnackLunchP.M. SnackSupper
Child's Name 2

First NameLast Name
Date

MonthDayYear
Date
YesNo
SundayMondayTuesdayWednesdayThursdayFridaySaturday
Input Normal Days of Care
BreakfastA.M. SnackLunchP.M. SnackSupper
Child's Name 3

First NameLast Name
Date

MonthDayYear
Date
YesNo
SundayMondayTuesdayWednesdayThursdayFridaySaturday
Input Normal Days of Care
BreakfastA.M. SnackLunchP.M. SnackSupper
INCOME ELIGIBILITY INFORMATION Instructions:
Please check all that apply/and then fill out the parts specified.
A member of my household receives SNAP (former Food Stamps) and/or TANF benefits.→ Complete Part 2 and Part 6.One or more of my children participates in Head Start / Early Head Start at this center.→ Complete Part 3 and Part 6.My household includes one or more foster children.→ Complete Part 4 and Part 6.My child(ren) may qualify for free or reduced-price meals based on household income.→ Complete Part 5 and Part 6.My child(ren) will not qualify for free or reduced-price meals.→ Complete Part 6 only.
PART 2 — HOUSEHOLD MEMBERS RECEIVING SNAP &/or TANF BENEFITS

If any household member gets SNAP (Food Stamps) and/or TANF benefits, list the recipient’s name, circle benefit type(s), and give the case number.
Name of Benefit Recipient*

First NameLast Name
SNAPTANF
SNAP / TANF Case Number (required — not SSN or EBT#):
PART 3 — CHILD(REN) ENROLLED IN HEAD START

If the enrolled child(ren) participates in Head Start/Early Head Start, write the name(s) below:
Name of Child 1 *

First NameLast Name
Name of Child 2

First NameLast Name
Name of Child 3

First NameLast Name
PART 4 — FOSTER CHILDREN
Name of Foster Child 1*

First NameLast Name
Name of Foster Child 2

First NameLast Name
Name of Foster Child 3

First NameLast Name
Households with foster children only:
Write the child(ren)’s name(s) here, then skip to Part 6.

Households with foster & non-foster children:
Write foster child(ren)’s name(s) here. If you did not complete Part 2, you must complete Part 5 to qualify non-foster child(ren) for free/reduced-price meals. You may include foster child(ren) in Part 5 with non-foster child(ren). This makes it easier for non-foster child(ren) to qualify for free/reduced-price meals. If you choose to list the foster child(ren) in Part 5, you must report any personal income received by the foster child(ren). You do not have to report payments that you receive from the placement agency to support the foster child(ren). If you completed Part 2, skip Part 5. All complete Part 6.
PART 5 — TOTAL HOUSEHOLD INCOME (Not required if Part 2 or Part 3 is completed.)

Input how much income and how frequently that amount is received: weekly, every two weeks (biweekly), twice a month (semimonthly), once a month (monthly), or annually.
CENTER NAME:
Gross Income (before Taxes or Deductions) from Last Month (if none, write "0")
List Names (First and Last) of Everyone in Your Household
Name of Child 1*

First NameLast Name
Earnings From Work Before Deductions
Income*
Frequency*
Alimony, Child Support, Welfare, etc.
Income*
Frequency*
Pensions, Retirement, Social Security, VA, etc.
Income*
Frequency*
Second Job or Any Other Income
Income*
Frequency*
Name 0f Child 2

First NameLast Name
Earnings From Work Before Deductions
Income
Frequency
Alimony, Child Support, Welfare, etc.
Income
Frequency
Pensions, Retirement, Social Security, VA, etc.
Income
Frequency
Second Job or Any Other Income
Income
Frequency
Name of Child 3

First NameLast Name
Earnings From Work Before Deductions
Income
Frequency
Alimony, Child Support, Welfare, etc.
Income
Frequency
Pensions, Retirement, Social Security, VA, etc.
Income
Frequency
Second Job or Any Other Income
Income
Frequency
Name 4

First NameLast Name
Earnings From Work Before Deductions
Income
Frequency
Alimony, Child Support, Welfare, etc.
Income
Frequency
Pensions, Retirement, Social Security, VA, etc.
Income
Frequency
Second Job or Any Other Income
Income
Frequency
PART 6 — CERTIFICATION, SIGNATURE, AND SOCIAL SECURITY NUMBER (LAST 4 DIGITS)

The adult household member who fills out this form must sign below. If Part 5 is completed, the adult signing the form must provide the last four (4) digits ONLY of his/her Social Security Number (SSN), or check “I do not have a Social Security Number.” (See Privacy Act Statement on the back of this page.)The last four digits of your SSN are NOT needed if you have checked “My child(ren) will not qualify for Free/Reduced-Price meals” or if you have listed a TANF or SNAP case number or are applying for Head Start or foster child(ren) only. CERTIFICATION: I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds; that institution official(s) may verify the information on the application; and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws.
Printed Name of Parent/Guardian*

First NameLast Name
Signature of Parent/Guardian*

Powered by Jotform SignClear
Address*

Street Address

Street Address 2

CityState / Province

Postal / Zip Code
Last 4 Digits of SSN (XXX-XX-_ _ _ _)*
Date*

MonthDayYear
Date
Daytime Phone*
Please enter a valid phone number.Format: (000) 000-0000.
PART 7 — CIVIL RIGHTS INFORMATION: ENROLLED CHILD(REN)’S ETHNICITY & RACE (OPTIONAL)
Hispanic or LatinoNot Hispanic or Latino
American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
This information is requested solely for the purpose of determining the State’s compliance with Federal civil rights laws, and your response will not affect consideration of your application and may be protected by the Privacy Act. By providing this information, you will assist us in assuring that this Program is administered in a nondiscriminatory manner.
Non-discrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint, and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992.

Submit your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.
PRIVACY ACT STATEMENT
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve the participant for free or reduced-price meals. You must include the last four digits of the Social Security Number of the adult household member who signs the application. The Social Security Number is not required when you list a case number for the Supplemental Nutrition Assistance Program (SNAP) and/or the Temporary Assistance for Needy Families (TANF) Program, submit an application on behalf of a foster child only, or when you indicate that the adult household member signing the application does not have a Social Security Number. We will use your information to determine if the participant is eligible for free or reduced-price meals, and for administration and enforcement of the Program.

Verification efforts may be carried out through program reviews, audits, and investigations and may include contacting the Child and Family Services Agency to verify foster child status; contacting the Income Maintenance Administration office to confirm receipt of SNAP and/or TANF benefits; contacting employers to determine income; and/or checking the documentation produced by the household member to verify the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported.
FISCAL YEAR:
PART 1 – ENROLLMENT INFORMATION
Name(s) of Enrolled Child(ren)*

First NameLast Name

Type a question

Rows	Not Satisfied	Somewhat Satisfied	Satisfied	Any thoughts?
Date of Birth
Before & After Care
Print Normal Hours of Care
Friendliness

- If any household member gets SNAP (Food Stamps) and/or TANF benefits, list the recipient’s name, circle benefit type(s), and give the case number.
- Should be Empty:

KD'S Food Program Enrollment Form

PART 1 – ENROLLMENT INFORMATION

PART 2 — HOUSEHOLD MEMBERS RECEIVING SNAP &/or TANF BENEFITS

PART 3 — CHILD(REN) ENROLLED IN HEAD START

PART 4 — FOSTER CHILDREN

PART 5 — TOTAL HOUSEHOLD INCOME (Not required if Part 2 or Part 3 is completed.)

PART 6 — CERTIFICATION, SIGNATURE, AND SOCIAL SECURITY NUMBER (LAST 4 DIGITS)

PART 7 — CIVIL RIGHTS INFORMATION: ENROLLED CHILD(REN)’S ETHNICITY & RACE (OPTIONAL)

PRIVACY ACT STATEMENT