"Child and Adult Care Food Program (CACFP) Provider Application Change Form" - Arizona

Child and Adult Care Food Program (CACFP) Provider Application Change Form is a legal document that was released by the Arizona Department of Education - a government authority operating within Arizona.

Form Details:

  • Released on July 25, 2019;
  • The latest edition currently provided by the Arizona Department of Education;
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Arizona Department of Education
Health & Nutrition Services Division
Child and Adult Care Food Program (CACFP) Provider Application Change Form
Instructions: Complete only the applicable fields on this document to make changes to an existing approved application. If the
provider is moving, changing approval types, requesting a name change or transferring, a full application is required with all
required supporting documents.
Name of Sponsoring Organization:
REQUIRED – Please Print Clearly – Complete Provider’s Name and Address:
Provider’s Name:
Provider’s DOB:
Physical Address:
City:
Zip Code:
Please identify any changes being made to the initial application for any of the sections below.
Section 1 – Provider Details:
Field Name
Updated Information
Field Name
Updated Information
Phone:
Email Address:
Backup Providers: For all new backup providers, include fingerprint card or application as a separate attachment.
Backup Provider Name
FPC Expiration
New Backup Provider?
Remove Backup Provider
Date
Yes
No
Yes
No
Yes
No
Yes
No
Section 2 – Provider Application Changes:
Day of Week
New Hours of
New Hours of
Day of Week
New Hours of
New Hours of
Care - Start Time
Care - End Time
Care - Start Time
Care - End Time
Monday
Saturday
Tuesday
Sunday
Wednesday
Explain variations in days or hours of care.
Thursday
Friday
Kathy Hoffman, Superintendent of Public Instruction
1535 West Jefferson Street, Phoenix, Arizona 85007 • (602) 542-8700 • www.azed.gov
This institution is an equal opportunity provider.
Revised 7/25/2019
Arizona Department of Education
Health & Nutrition Services Division
Child and Adult Care Food Program (CACFP) Provider Application Change Form
Instructions: Complete only the applicable fields on this document to make changes to an existing approved application. If the
provider is moving, changing approval types, requesting a name change or transferring, a full application is required with all
required supporting documents.
Name of Sponsoring Organization:
REQUIRED – Please Print Clearly – Complete Provider’s Name and Address:
Provider’s Name:
Provider’s DOB:
Physical Address:
City:
Zip Code:
Please identify any changes being made to the initial application for any of the sections below.
Section 1 – Provider Details:
Field Name
Updated Information
Field Name
Updated Information
Phone:
Email Address:
Backup Providers: For all new backup providers, include fingerprint card or application as a separate attachment.
Backup Provider Name
FPC Expiration
New Backup Provider?
Remove Backup Provider
Date
Yes
No
Yes
No
Yes
No
Yes
No
Section 2 – Provider Application Changes:
Day of Week
New Hours of
New Hours of
Day of Week
New Hours of
New Hours of
Care - Start Time
Care - End Time
Care - Start Time
Care - End Time
Monday
Saturday
Tuesday
Sunday
Wednesday
Explain variations in days or hours of care.
Thursday
Friday
Kathy Hoffman, Superintendent of Public Instruction
1535 West Jefferson Street, Phoenix, Arizona 85007 • (602) 542-8700 • www.azed.gov
This institution is an equal opportunity provider.
Revised 7/25/2019
Updated
Updated
Holiday Care
Holiday Care
Information
Information
Thanksgiving Day
Check all that apply:
New Year’s Day
Christmas
Memorial Day
Presidents Day
July 4th
Veterans Day
Other
MLK Day
Columbus Day
Labor Day
Providers Own Children
How many of Provider’s own children will be claimed:
Section 3 – Meal Service:
1
Shift
2
Shift
How Often?
st
nd
Meals
New
New
New
New
Wk.
Wk.
Holi-
Other
Describe Other
Claimed
Start
End
Start
End
Days
Ends
days
(1
Shift)
Time
Time
Time
Time
st
Breakfast
AM Snack
Lunch
PM Snack
Supper
Eve Snack
I, (name of sponsor rep)
_ hereby certify any of the above changes made to the
initial application have been communicated by the provider to the sponsoring agency and have been approved
effective on this date
.
Change request was received from provider by:
Email
Phone
Other
Sponsor Representative Signature
Date
www.azed.gov
2
1535 West Jefferson Street, Phoenix, Arizona 85007 • (602) 542-8700 •
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