Food Program Form CACFP

FOOD PROGRAM (CACFP) FORM
Type a question

NEWUPDATE
Institution Name: CHILD CARE PLUS
Agreement Number: CE ID 02051
Facility/Provider Name:Promise Land Day Care Center 1325

Child and Adult Care Food Program (CACFP) Participant Enrollment Form Your day care facility participates in the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP The enrolled participant will receive nutritious meals and snacks at no cost to you. CACFP needs verification of enrollment for each participant in this facility. Please fill out the parent/guardian section of this form, sign it and return it to the above facility/provider. Provide information for one participant per section. (In order for the institution to receive reimbursement for meals served/claimed, this form must be completed for each enrolled participant annually)
Participant's (Child) Name*
Date of Birth*

MonthDayYear
Date
Age*
Sex*

MaleFemale
Date participant enrolled in the facility*

MonthDayYear
Date
Food Allergies*

YesNo
If yes specify
(If the participant cannot be served the CACFP Meal Pattern, a statement from the participant's Health Care Provider must be provided)
Check Days of Normal Care at facility:*

MondayTuesdayWednesdayThursdayFriday
Check meals normally eaten at facility:*

BreakfastLunchPM Snack
Please list the normal times of arrival and departure (check am or pm)
Arrival*

Hour Minutes

AM/PM Option
Departure*

Hour Minutes

AM/PM Option
RACE OF PARTICIPANT: You are NOT required to answer this question.

WhiteBlack or African AmericanAmerica Indian/Alaska NativeAsianNative Hawaiian or Other Pacific Islander
ETHNIC IDENTITY: You are NOT required to answer this question.

Hispanic or LatinoNot Hispanic or Latino
If participant is an infant 0-11 Months, please complete this box, check all applicable choice(s) below:
This institution/facility offers: Similac Advance & Enfamil Gentle-Ease formula for infants through CACFP. It is your choice wether or not to use this formula based on your infant's needs. Baby foods provided by the institution/facility must be in compliance with the infant meal pattern as required by 7CFR 226.20.

Please mark your preference (Choose all that apply)

	Today's Date/ Birth-5 Months	Today's Date/6-11 Months
I will bring expressed breastmilk for my infant
I want the provider to provide the infant formula for my infant (write down which: Similac Advance or Enfamil Gentle-Ease)
I will bring the infant formula for my infant. Please list the kind of infant formula you will bring.

According to CACFP requirements, in order to claim meals for reimbursement, the provider must provide infant cereal and other foods when your infant is developmentally ready to accept them. Please mark your preference:

	Today's Date/6-11 Months
I want the provider to provide the infant cereal and other foods for my infant.
I will bring the infant cereal and/or other foods for my infant.

Note to parents who are getting formula through the WIC program: Your baby is eligible to get formula from this child care institution/facility as well as from the WIC program. It is your decision which formula you want your baby to use when she/he is at child care. If you find you are getting more formula than your baby needs, you may wish to talk with your WIC nutritionist or your child care provider.
I hereby certify the information given on this sheet is true and correct to the best of my knowledge. I also certify that I was given CACFP Meal Benefits Income Eligibility Form Letter to Household, the WIC information, Building for the Future Flyers, Civil Rights Appeals Procedures.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Print Name*
Address*

Address

Street Address Line 2

CityState

Zip Code
Home Telephone Number*
Work Telephone Number
Emergency Telephone Number
Date Dropped*

MonthDayYear
Date
In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA Director Office of Adjudication and Compliance, 1400 Independence Avenue SW, Washington, DC 20250-9401 or call (866) 632-9992, (202) 260-1026 or (202) 401-0216 (TDD This institution is an equal opportunity provider and employer.
CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)
PART 1: LIST ALL HOUSEHOLD MEMBERS:
Name of Enrolled Child:*

Please mark your preference (Choose all that apply)*

	Names of ALL HOUSEHOLD MEMBERS (First, Middle Initial, Last)	Check if a foster child (The legal responsibility of a welfare Agency or Court) *If all children listed below are foster children, skip to part 5 to sign this form)	Check if NO INCOME
Member No. 1
Member No. 2
Member No. 3
Member No. 4
Member No. 5
Member No. 6
Member No. 7

PART 2. Benefits: If any member of your household receives SNAP, TANF, or FDPIR, provide the name and eligibility number for the person who receives benefits. If no one receives these benefits, skip to part 3.
NAME
ELIGIBILITY NUMBER
Part 3. (Applies only to parents/guardians with children enrolled in a day care home): If any member of your household receives benefits listed on the enclosed List of Eligible Federal/State Funded Programs (H1660), provide the name of the program and eligibility number:
NAME
ELIGIBILITY NUMBER
Check here if no eligibility number
Part 4. Total Household Gross Income-You must tell us how much and how often

B. Gross income and how often it was received Note: Self-employed report income after expenses in box 1

Total Household Gross income: (type amount / and how often)*

	A. Name (List ONLY household members with income) Example: Jane Smith	1. Earnings from work before deductions Example: $200/Weekly	2. Welfare, child support, alimony Example: $150/Twice a month	3. Pensions, retirement, Social Security, SSI, VA benefits Example: $100/monthly	4. All other income Example: $200/Bi-monthly
Member No. 1
Member No. 2
Member No. 3
Member No. 4
Member No. 5

Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign) An adult household member must sign this form. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the "I do not have a Social Security Number" box. (See Privacy Act Statement on the next page

I certify that all information on this form is true and that all income is reported. I understand that the center or day care 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.
Sign here*

Clear
Print name*
Date*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Last four (4) digits of Social Security Number*
I do not have a Social Security Number
CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)
Part 6. Participant's ethnic and racial identities.
Mark one ethnic identity:*

Hispanic or LatinoNot Hispanic or Latino
Mark one or more racial identities:*

AsianWhiteBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific Islander
Part 7: Sharing information with other programs: OPTIONAL - The above information may be disclosed for the purpose of enrolling children in the Children's Health Insurance Program (CHIP). Parents/guardians are not required to consent to such disclosure and electing not to allow disclosure will not adversely affect a child's eligibility.*

I DO elect to allow my household information to be disclosed.I DO NOT elect to allow my household information to be disclosed.
Should be Empty:

FOOD PROGRAM (CACFP) FORM

CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)