"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 is a legal document that was released by the Arizona Department of Education - a government authority operating within Arizona.

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Released on July 25, 2019;
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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

Check all that apply:  New Year’s Day

Mon

AM / PM to

AM / PM

 Memorial Day  July 4

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

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

AM Snack

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

Lunch

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

PM Snack

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

Supper

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

Eve Snack

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

Check all that apply:  New Year’s Day

Mon

AM / PM to

AM / PM

 Memorial Day  July 4

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

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

AM Snack

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

Lunch

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

PM Snack

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

Supper

 Weekdays  Weekends  Holidays/school breaks  Rarely  Other ____________________

Eve Snack

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