"Child & Adult Care Food Program (CACFP) Center/Site Application" - Georgia (United States)

Child & Adult Care Food Program (CACFP) Center/Site Application is a legal document that was released by the Georgia Department of Early Care and Learning - a government authority operating within Georgia (United States).

Form Details:

  • Released on November 1, 2017;
  • The latest edition currently provided by the Georgia Department of Early Care and Learning;
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Download "Child & Adult Care Food Program (CACFP) Center/Site Application" - Georgia (United States)

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Child & Adult Care Food Program (CACFP) Center/Site Application
Center’s Legal Name
Doing Business Name of Center
Federal Employer Identification #
SECTION 1: SITE INFORMATION
1.
Site Type (Check all that apply)
Free Enrollment
Reduced Enrollment
Paid Enrollment
Total Enrollment
____ Adult Care Center
____ Child Care Center Enrollment
Select type below:
___ Child Care
___ Head Start Only
___ Outside School Hours
___ At-Risk Afterschool Care Center
___ Homeless/Emergency Shelter
Tax Status: ___ For-Profit ___ Private Non Profit ___ Non Profit (Church) ___ Public Non-Profit (School. Govt., etc.)
Tax Exempt Status Date: ____________
If For-Profit, select all that apply (eligibility status) and provide enrollment:
___ Title XIX/XX (Adult Care Center) Enrollment ___ (Enrollment)
___ Title XX (Child Care Center) Enrollment ___ (Enrollment) and/or Pre-K Category 1 ___
___ Free and Reduced Meal Participant (Childcare Center) | Enrollment: Free ___ Reduced ___ Paid ___
2.
Will this site also participate in the summer Food Service Program? ___Yes ___No
2a. Is the center listed in this application owned (in part or whole) by the Institution who is currently participating in the CACFP and submitting this
Center/Site Application for approval? ___Yes ___No (If No, please select the appropriate ownership code below in item 2c.)
2b. Ownership Code: ___Sole Owner ___Limited Liability Company ___ Corporation ___Government ___Partnership ___ Out of State Corporation
2c. Does the center charge a separate fee for meals? ___Yes ___No (If Yes, submit Written Free & Reduced Policy Statement.)
SECTION 2: LICENSE / REGISTRATION INFORMATION
3.
Licensed Type: ____________________
4.
License Number: ____________________
5.
License Effective Date: ____________________
6.
License Capacity: ____________________
7.
Building Capacity: ____________________
8.
Average Daily Attendance: ____________________
9.
Fire Inspection Date: ____________________
10. Food Inspection Date: ____________________
11. Do you provide child care for infants under 12 months old? ___ Yes ___ No
SECTION 3: PHYSICAL ADDRESS
12. Address Line 1: ________________________________________ Address Line 2: ________________________________________
13. City: ____________________
14. State: _____ Zip: __________
15. County: ____________________
Child & Adult Care Food Program (CACFP) Center/Site Application
Center’s Legal Name
Doing Business Name of Center
Federal Employer Identification #
SECTION 1: SITE INFORMATION
1.
Site Type (Check all that apply)
Free Enrollment
Reduced Enrollment
Paid Enrollment
Total Enrollment
____ Adult Care Center
____ Child Care Center Enrollment
Select type below:
___ Child Care
___ Head Start Only
___ Outside School Hours
___ At-Risk Afterschool Care Center
___ Homeless/Emergency Shelter
Tax Status: ___ For-Profit ___ Private Non Profit ___ Non Profit (Church) ___ Public Non-Profit (School. Govt., etc.)
Tax Exempt Status Date: ____________
If For-Profit, select all that apply (eligibility status) and provide enrollment:
___ Title XIX/XX (Adult Care Center) Enrollment ___ (Enrollment)
___ Title XX (Child Care Center) Enrollment ___ (Enrollment) and/or Pre-K Category 1 ___
___ Free and Reduced Meal Participant (Childcare Center) | Enrollment: Free ___ Reduced ___ Paid ___
2.
Will this site also participate in the summer Food Service Program? ___Yes ___No
2a. Is the center listed in this application owned (in part or whole) by the Institution who is currently participating in the CACFP and submitting this
Center/Site Application for approval? ___Yes ___No (If No, please select the appropriate ownership code below in item 2c.)
2b. Ownership Code: ___Sole Owner ___Limited Liability Company ___ Corporation ___Government ___Partnership ___ Out of State Corporation
2c. Does the center charge a separate fee for meals? ___Yes ___No (If Yes, submit Written Free & Reduced Policy Statement.)
SECTION 2: LICENSE / REGISTRATION INFORMATION
3.
Licensed Type: ____________________
4.
License Number: ____________________
5.
License Effective Date: ____________________
6.
License Capacity: ____________________
7.
Building Capacity: ____________________
8.
Average Daily Attendance: ____________________
9.
Fire Inspection Date: ____________________
10. Food Inspection Date: ____________________
11. Do you provide child care for infants under 12 months old? ___ Yes ___ No
SECTION 3: PHYSICAL ADDRESS
12. Address Line 1: ________________________________________ Address Line 2: ________________________________________
13. City: ____________________
14. State: _____ Zip: __________
15. County: ____________________
Child & Adult Care Food Program (CACFP) Center/Site Application
SECTION 4: MAILING ADDRESS
16. Address Line 1: ________________________________________ Address Line 2: ________________________________________
17. City: ____________________
18. State: _____ Zip: __________
SECTION 5: DIRECTIONS
19. Enter driving directions to your site from Atlanta, GA:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
SECTION 6: CENTER CONTACT – Person in charge of this center on a daily basis
20. Name: Salutation: ________ First Name: _________________________ Last Name: _________________________
21. Date of Birth (mm/dd/yyyy): ____________________
22. Email Address: ____________________
23. Facility Phone: ____________________ Ext. _____ Fax: _____
24. Cell/Alt Phone: ____________________
25. Title: ____________________ Director: ____________________
SECTION 7: SCHEDULE
26. A. Months of Operation (Check all that apply)
All: ___ Jan: ___ Feb: ___ Mar: ___ Apr: ___ May: ___ Jun: ___ Jul: ___ Aug: ___ Sep: ___ Oct: ___ Nov: ___ Dec: ___
B. Days of Operation (Check all that apply)
Mon-Fri: ___ Mon: ___ Tue: ___ Wed: ___ Thu: ___ Fri: ___ Sat: ___ Sun: ___
Regular Schedule
27. Normal Hours of Operations: Time Open: _____ Time Close: _____
28. Regular Meals
Regular Meals
First Shift
Second Shift (Optional)
Meals
Start Time
End Time
Start Time
End Time
Breakfast
AM Snack
Lunch
PM Snack
Supper
Late Night Snack
29. At-Risk Meals
At-Risk Meals
Traditional School Day
Vacation/Holiday Shift (Optional)
Meals
Start Time
End Time
Start Time
End Time
Breakfast
AM Snack
Lunch
PM Snack
Supper
Late Night Snack
Weekend Schedule
30. Weekend Hours of Operations: Time Open: _____ Time Close: _____
31. Additional Institution notes related to Meal Service:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________.
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CACFP Center/Site Application-11.2017
Child & Adult Care Food Program (CACFP) Center/Site Application
SECTION 8: AT-RISK SITE ONLY
32. Select At-Risk activities that apply: ___ Educational ___ Enrichment
33. Please enter a description of the educational and/or enrichment program(s).
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
34. Enter the elementary, middle, or high school a child would attend if he/she lived next door to this site:
School District: ___________________________________________
School Name: ______________________________________________________________________________________________
Free and Reduced Meal Eligibility (%): __________
Eligibility – Start Year: __________
Eligibility – Expiration Year: __________
Is After School Program located in a Public School building? ___Yes __No
Is the After School Program and Expanded Learning Time Program? ___Yes ___No
List the names and work hours for the staff that supervise the After School Program:
Name: _________________________________________________________ Work Hours:________________________________
Name: _________________________________________________________ Work Hours:________________________________
Name: _________________________________________________________ Work Hours:________________________________
Name: _________________________________________________________ Work Hours:________________________________
Name: _________________________________________________________ Work Hours:________________________________
SECTION 9: FOOD SERVICE
35. How are the meals prepared? Prepared on site ___ Prepared at Central Facility ___ Contracted ___ School Food Authority ___ Other ___
If Other, please explain: _________________________________________________________________________________________________.
36. How are meals served? Individual Meals ___ Family Style ___
37. Do you have a food service contract? Yes ___ No ___
38. Name of Food Service Vendor: ___________________________________________________________
39. Contract Period: ____________________ From: ____________________ To: ____________________
40. Which meal types does offer vs. serve apply? Breakfast ___ Lunch ___ Supper ___ None ___
SECTION 10: Ethnicity Data
41. Select the name of a school in the zone in which the site is located. (All programs): ___________________________________________________
42. Provide the ethnic makeup of the participants served by the Institution’s service area. (Racial and Ethnic Data percentages can be found on Bright
from the Start’s website at http://www.decal.ga.gov/documents/attachments/RacialEthnic17.pdf)
Geographic Area (enter percentages):
School %
Hispanic or Latino:
_____%
Non-Hispanic or Latino:
_____%
Provide the ethnic makeup of the participants served by the Institution. Provide actual numbers of enrolled participants at all sites.
43. Participation Area (enter number of enrolled participants):
Hispanic or Latino: ____________________
Non-Hispanic or Latino: ____________________
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CACFP Center/Site Application-11.2017
Child & Adult Care Food Program (CACFP) Center/Site Application
SECTION 11: RACIAL DATA
44. Provide the racial makeup of the participants served by the Institution’s service area. (Racial and Ethnic Data percentages can be found on Bright
from the Start’s website at http://www.decal.ga.gov/documents/attachments/RacialEthnic17.pdf)
45.
Geographic Area (enter percentages):
School %
American Indian or Alaskan Native:
_____%
Asian:
_____%
Black or African American:
_____%
Native Hawaiian or Pacific Islander:
_____%
White:
_____%
Provide the racial makeup of the participants served by the Institution. Provide actual numbers of enrolled participants at all sites.
Program Participants (enter number of enrolled participants):
American Indian or Alaskan Native: _____
Asian: _____
Black or African American: _____
Native Hawaiian or Pacific Islander: _____
White: _____
SECTION 12: COMMENTS FROM INSTITUTION
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
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CACFP Center/Site Application-11.2017
Child & Adult Care Food Program (CACFP) Center/Site Application
ADDITIONAL CERTIFICATIONS:
Complete the certification section applicable to your program type. If the center is a child care center including Head Starts, Outside School
Hours and At Risk Centers, check the Child Care Certification. If an Emergency Shelter, check the Emergency/Homeless Shelter Certification.
CHILD CARE CENTER CERTIFICATION
Each statement below must be true to qualify. All child care centers other than Emergency/Homeless Shelters must certify to each statement
below. If a statement is left unchecked, the organization is indicating that it does not qualify for the program, and the application will be
denied.
I understand that child care centers must be providing DAY CARE, Pre-K, or Head/Early Start services to enrolled children, and I certify that
the program for which this application is made qualifies.
I understand that centers whose primary purpose is for substance abuse treatment or rehabilitation, and whose participant eligibility is
based upon a substance abuse diagnosis are not eligible for the CACFP, and I certify that my program does not fall under this category.
EMERGENCY/HOMELESS SHELTER CERTIFICATION
I understand that shelters eligible to participate may be serving children unaccompanied by their parents or guardians as a result of
circumstance or be placed in the shelter temporarily by a State Authority (in State custody rather than parents).
I understand that shelters serving homeless children and their families may participate but only meals for children up to the age of 18 may
be claimed for reimbursement.
CHECK THE APPLICABLE STATEMENT BELOW:
I understand that if my program is licensed as a Residential Child Care Institution (RCCI), the organization may participate in the CACFP as an
emergency shelter only for service to a distinct group of homeless children who are not enrolled in the RCCI’s regular program.
I certify that the emergency/homeless shelter making an application is not licensed as a Residential Child Care Institution.
SECTION 13: CERTIFICATIONS
I hereby certify that neither the Sponsor nor its principals/authorized representatives is presently terminated, suspended, proposed for
termination, declared ineligible, disqualified, or voluntarily excluded from participation in this transaction by any Federal/State department or
agency.
I certify under penalty of perjury that the information on these application forms is true and correct, and that I will immediately report to the State
any changes that occur to the information submitted. I understand that this information is being given in connection with receipt of federal funds.
The State may verify information; and the deliberate misrepresentation of information will subject me to prosecution under applicable federal and
state criminal statutes.
On behalf of the Sponsor, I hereby agree to comply with all state and federal laws and regulations governing the Child Nutrition Programs
administered by the State. In accordance with Federal law and U.S. Department of Agriculture policy, this Sponsor does not discriminate on the
basis of race, color, national origin, sex, age or disability. I will ensure that all monthly claims for reimbursement are true and correct and that
records are available to support these claims.
*SIGNATURE of PRINCIPCAL of ORGANIZATION MAKING THE APPLICATION: ________________________________________________________
PRINTED NAME of PRINCIPAL: __________________________________________________________
DATE: _______________________
*The Principal of the organization is the Executive Director, Owner, Superintendent, CEO, or other person who has been delegated as Principal
to assume legal responsibility for the organization. In many cases the director of the day care center will not be the principal unless the
director also fulfills one of the roles listed earlier. This person must also sign the Agreement for Participation with Bright from the Start or the
Agreement with the Administrative Sponsor.
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CACFP Center/Site Application-11.2017
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