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

"Child and Adult Care Food Program (CACFP) Child Care Home Provider Application" - Arizona Download Pdf
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Child and Adult Care Food Program (CACFP) Child Care Home Provider Application 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;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Arizona Department of Education.

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Download "Child and Adult Care Food Program (CACFP) Child Care Home Provider Application" - Arizona

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Child and Adult Care Food Program (CACFP) Child Care Home Provider Application FY 20____
Name of Sponsoring Organization:
 New Provider  Renewing/Continuing Provider  Change of Address  Provider Transfer
Application Type:
PLEASE PRINT CLEARLY
Provider’s Name:
Last 4 digits of SSN:
__ Date of Birth:
___ Cell Phone:____________________________
Physical Address:
________
____________________ City:
______________________Zip:
Home Phone:
_______________________________
Providers email address: _______________________________________________
List anything that restricts access to the property (i.e. gated community, locked entry, loose dogs, etc):
__________________________
Name of Backup Provider:
___Exp. Date of Backup Fingerprint card___________________
Provider Home is:
Alternately Approved (Private)
DES Certified
DHS Certified
Military Certified
Tribal Certified
Days and hours child care will regularly be provided
Explain any variations in days or hours of care:
Federal holidays provided?
Yes
No
Check all that apply:  New Year’s Day
Mon
AM / PM to
AM / PM
 Memorial Day  July 4
th
Tues
AM / PM to
AM / PM
 Labor Day  Thanksgiving Day
Wed
AM / PM to
AM / PM
 Christmas Day
Thurs
AM / PM to
AM / PM
 MLK Day  Columbus Day
Fri
_______AM / PM to
AM / PM
 Presidents Day  Veterans Day
Sat
_
AM / PM to
AM / PM
 Other
Sun
_
AM / PM to
AM / PM
Below, list meals that will be regularly claimed and times meals will be served:
Provider claims own children?
Yes
No If Yes, how many:
Meals Claimed
Meal Times
Second Shift (If applicable)
_____________________
How often?
(select all that apply)
________________________________
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
Breakfast
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
AM Snack
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
Lunch
__
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
PM Snack
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
Supper
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
Eve Snack
to
to
I hereby certify that all of the above information is true and correct as of this date. I understand that this information is being given in connection with the receipt of federal funds; that
ADE officials may, for cause verify information, and that deliberate misrepresentation may subject me to prosecution under applicable state and federal criminal statutes.
Was NEW provider checked against the NDL: __________
Did provider receive licensing assistance?
_____YES
____NO
Provider’s Signature
________________
__
Date
_______
Sponsor Representative _______
______________
__
Date
________
This institution is an equal opportunity provider.
“Each day care home participating in the program shall serve the meal types specified in its approved application in accordance with the meal pattern requirements specified in 7 CFR 226.20.
Revised 07/25/2019
Child and Adult Care Food Program (CACFP) Child Care Home Provider Application FY 20____
Name of Sponsoring Organization:
 New Provider  Renewing/Continuing Provider  Change of Address  Provider Transfer
Application Type:
PLEASE PRINT CLEARLY
Provider’s Name:
Last 4 digits of SSN:
__ Date of Birth:
___ Cell Phone:____________________________
Physical Address:
________
____________________ City:
______________________Zip:
Home Phone:
_______________________________
Providers email address: _______________________________________________
List anything that restricts access to the property (i.e. gated community, locked entry, loose dogs, etc):
__________________________
Name of Backup Provider:
___Exp. Date of Backup Fingerprint card___________________
Provider Home is:
Alternately Approved (Private)
DES Certified
DHS Certified
Military Certified
Tribal Certified
Days and hours child care will regularly be provided
Explain any variations in days or hours of care:
Federal holidays provided?
Yes
No
Check all that apply:  New Year’s Day
Mon
AM / PM to
AM / PM
 Memorial Day  July 4
th
Tues
AM / PM to
AM / PM
 Labor Day  Thanksgiving Day
Wed
AM / PM to
AM / PM
 Christmas Day
Thurs
AM / PM to
AM / PM
 MLK Day  Columbus Day
Fri
_______AM / PM to
AM / PM
 Presidents Day  Veterans Day
Sat
_
AM / PM to
AM / PM
 Other
Sun
_
AM / PM to
AM / PM
Below, list meals that will be regularly claimed and times meals will be served:
Provider claims own children?
Yes
No If Yes, how many:
Meals Claimed
Meal Times
Second Shift (If applicable)
_____________________
How often?
(select all that apply)
________________________________
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
Breakfast
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
AM Snack
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
Lunch
__
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
PM Snack
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
Supper
to
to
 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________
Eve Snack
to
to
I hereby certify that all of the above information is true and correct as of this date. I understand that this information is being given in connection with the receipt of federal funds; that
ADE officials may, for cause verify information, and that deliberate misrepresentation may subject me to prosecution under applicable state and federal criminal statutes.
Was NEW provider checked against the NDL: __________
Did provider receive licensing assistance?
_____YES
____NO
Provider’s Signature
________________
__
Date
_______
Sponsor Representative _______
______________
__
Date
________
This institution is an equal opportunity provider.
“Each day care home participating in the program shall serve the meal types specified in its approved application in accordance with the meal pattern requirements specified in 7 CFR 226.20.
Revised 07/25/2019
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"Child and Adult Care Food Program (CACFP) Child Care Home Provider Application" - Arizona Download Pdf
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