"Child Enrollment Application for the Child and Adult Care Food Program" - Arizona

Child Enrollment Application for the Child and Adult Care Food Program is a legal document that was released by the Arizona Department of Education - a government authority operating within Arizona.

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Download "Child Enrollment Application for the Child and Adult Care Food Program" - Arizona

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CHILD ENROLLMENT APPLICATION FOR THE CHILD AND ADULT CARE FOOD PROGRAM
FY 20____
Your child care provider,
participates in the Child and Adult Care Food
(PROVIDER NAME)
Program (CACFP). This program extends the benefits of the National School Lunch program to children in family child
care homes. Your child care provider is sponsored on the CACFP by
.
(SPONSOR)
Under the regulations of the Child and Adult Care Food Program your provider may not charge you separate fees for
meals nor ask you to provide food for your child for those meals claimed under the program, including infants. A
maximum of 2 meals and 1 snack or 2 snacks and 1 meal may be reimbursed per day for your child(ren) on the Child and
Adult Care Food Program. All enrolled participants are served the same meals at no separate charge, regardless of race,
color, national origin, sex, age or disability.
Verification procedures may be conducted to ensure that your provider’s claims for reimbursement are consistent with
child care services provided. As the sponsor for your provider, we must verify that your child is enrolled in the home for
child care. Please complete the following:
I wish to enroll the following children in the CACFP:
CHILD(REN’S) FULL NAME
BIRTH DATE
NAME OF SCHOOL
SCHOOL HOURS
(enter “none” if not applicable)
Is school year round?
Yes
No
Is transportation needed to/from school?
Yes
No
Are your children (check all that apply):
Type of formula offered:
Provider’s Own Child/Residential
Day Care Child
Accept
New Enrollment
Continuing Enrollment
Decline (I will provide:
)
For Compensation
Not for Compensation
Not Applicable
Days child care will normally be needed:
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Hours of care will normally be needed from:
AM / PM to
AM / PM
Will days and/or hours of care vary at any time?
Yes
No
If Yes, please explain:
Will holiday care be needed?
Yes
No
If Yes, please explain:
Check meals served to your child while in day care:
Breakfast
Lunch
Supper
Snack(s)
PARENT SIGNATURE
WORK PHONE #
HOME/MESSAGE PHONE
ADDRESS
CITY
ZIP
DATE
Racial-Ethnic Heritage of YOUR child(ren): Although you are not required to provide this information, your cooperation will help determine compliance with Federal Civil Rights
Law. In no instance will this information be used in considering your application. If you decline to provide this information, it will no way affect consideration of your
application. We are authorized to ask for this information under Title VI of the Civil Rights Act of 1964. Collection of this information is strictly for statistical reporting
requirements. Please circle correct category below (if willing):
Black-not of
Hispanic
Asian or Pacific
American Indian or
White-not of
Other
Hispanic Origin
Islander
Alaskan Native
Hispanic Origin
CONFIDENTIALITY: The information you provide will be treated confidentially and will be used only for eligibility determinations and verification of data for Child and Adult
Care Food Program purposes.
Arizona Department of Education · Health & Nutrition Services · 602-542-8700
This institution is an equal opportunity provider.
CHILD ENROLLMENT APPLICATION FOR THE CHILD AND ADULT CARE FOOD PROGRAM
FY 20____
Your child care provider,
participates in the Child and Adult Care Food
(PROVIDER NAME)
Program (CACFP). This program extends the benefits of the National School Lunch program to children in family child
care homes. Your child care provider is sponsored on the CACFP by
.
(SPONSOR)
Under the regulations of the Child and Adult Care Food Program your provider may not charge you separate fees for
meals nor ask you to provide food for your child for those meals claimed under the program, including infants. A
maximum of 2 meals and 1 snack or 2 snacks and 1 meal may be reimbursed per day for your child(ren) on the Child and
Adult Care Food Program. All enrolled participants are served the same meals at no separate charge, regardless of race,
color, national origin, sex, age or disability.
Verification procedures may be conducted to ensure that your provider’s claims for reimbursement are consistent with
child care services provided. As the sponsor for your provider, we must verify that your child is enrolled in the home for
child care. Please complete the following:
I wish to enroll the following children in the CACFP:
CHILD(REN’S) FULL NAME
BIRTH DATE
NAME OF SCHOOL
SCHOOL HOURS
(enter “none” if not applicable)
Is school year round?
Yes
No
Is transportation needed to/from school?
Yes
No
Are your children (check all that apply):
Type of formula offered:
Provider’s Own Child/Residential
Day Care Child
Accept
New Enrollment
Continuing Enrollment
Decline (I will provide:
)
For Compensation
Not for Compensation
Not Applicable
Days child care will normally be needed:
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Hours of care will normally be needed from:
AM / PM to
AM / PM
Will days and/or hours of care vary at any time?
Yes
No
If Yes, please explain:
Will holiday care be needed?
Yes
No
If Yes, please explain:
Check meals served to your child while in day care:
Breakfast
Lunch
Supper
Snack(s)
PARENT SIGNATURE
WORK PHONE #
HOME/MESSAGE PHONE
ADDRESS
CITY
ZIP
DATE
Racial-Ethnic Heritage of YOUR child(ren): Although you are not required to provide this information, your cooperation will help determine compliance with Federal Civil Rights
Law. In no instance will this information be used in considering your application. If you decline to provide this information, it will no way affect consideration of your
application. We are authorized to ask for this information under Title VI of the Civil Rights Act of 1964. Collection of this information is strictly for statistical reporting
requirements. Please circle correct category below (if willing):
Black-not of
Hispanic
Asian or Pacific
American Indian or
White-not of
Other
Hispanic Origin
Islander
Alaskan Native
Hispanic Origin
CONFIDENTIALITY: The information you provide will be treated confidentially and will be used only for eligibility determinations and verification of data for Child and Adult
Care Food Program purposes.
Arizona Department of Education · Health & Nutrition Services · 602-542-8700
This institution is an equal opportunity provider.