Child Enrollment Form for the Child and Adult Care Food Program
Family Day Care Home
CHILD(REN)’S INFORMATION:
Child’s Name (1) Date of Birth _____ / _____ / _____
Month Day Year
Child’s Name (2) Date of Birth _____ / _____ / _____
Month Day Year
Home Address Home Phone
Normal Days of Care with the Provider: ___S ___ M ____T ___W ____TH ___F ___S • Check if Parent works multiple shifts
Normal Hours of Care with the Provider: _________________ AM ____________________ PM
Meal Participation with the Provider ____Breakfast _____Snack (AM) ____Lunch _____Snack (PM) _____Supper
SCHOOL INFORMATION:
School/Child Care Center (1) Grade (1)
School/Child Care Center (2) Grade (2)
My child(ren) participate(s) in the following meals at school, Head Start center, or child care center:
[ ] Breakfast [ ] AM Snack [ ] Lunch [ ] PM Snack [ ] Supper
PARENTAL INFORMATION:
Mother’s Name Work Hours
Work Name & Address Work Phone
Home Phone
Father’s Name Work Hours
Work Name & Address Work Phone
Home Phone
Are there any unusual guardianship or custodial relationships?
Persons authorized to pick up child(ren)
Special Needs of Child (1)
Medical Information (allergy, sickness, etc.)(1)
Special Needs of Child (2)
Medical Information (allergy, sickness, etc.)(2)
In case of injury of accident
Physician’s Name Physician’s Phone Hospital of Choice
I hereby give permission to treat my child(ren) in case of medical emergency.
Parent’s Signature Parent’s Signature Date
NAMES OF TWO OTHER PERSONS THAT CAN BE CONTACTED IN CASE OF EMERGENCY
Name
Address
Phone
Name
Address
Phone
My child (1) is: [ ] Related to Provider: Relationship_______________ [ ] Paying for Care
[ ] Not Related to Provider [ ] Not Paying for Care [ ] Notarized Statement on file
My child (2) is: [ ] Related to Provider: Relationship_______________ [ ] Paying for Care
[ ] Not Related to Provider [ ] Not Paying for Care [ ] Notarized Statement on file
I understand that my provider has applied to receive federal funds for meals served to my child(ren) and that I may be contacted to verify my child(ren)’s attendance. I
have attached current immunization record(s) for my child(ren).
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Child’s Age (1) Enrollment Date (1) Withdrawal Date (1)
Reason for Withdrawal
Child’s Age (2) Enrollment Date (2) Withdrawal Date (2)
Reason for Withdrawal
NOTE: Providers MUST retain emergency contact information for every child. Sponsors should retain a copy of this form to validate enrollment.
Revised 2/2005
CACFP
FSFA
PROVIDER