CHILD ENROLLMENT FORM FOR CHILD AND ADULT CARE FOOD PROGRAM (CACFP)
SPONSORING ORGANIZATION: PARTICIPATING CENTER:
Mason Meals Inc ______________________
1100 E Berks St _______________________
Philadelphia Pa 19125 ________________________
This document does not have to be completed for children in Emergency Shelters, Outside School Hours, and/or At-Risk programs. It is recommended to have new
CACFP Annual Enrollment Forms completed each year during the Household Eligibility Application renewal period. Review completed enrollment form and enter the
effective date in lower right hand section.
PARENTS: This institution participates in the Child and Adult Care Food Program (CACFP) and receives reimbursement to provide more nutritious meals for your
child(ren). Federal CACFP regulations require all parents and guardians to complete a CACFP Annual Enrollment Form when enrolling their child(ren) and again every
year thereafter. This information will help ensure all children receive appropriate meals during their care.
Please complete all areas to include signing and dating same.
FULL NAME OF ENROLLED
CHILD (Include Birth Date/Age
THIS CHILD NORMALLY ATTENDS DURINIG WEEK
MEALS RECEIVED
TIME-IN
TIME OUT
TIME CHILD ATTENDS
SCHOOL
DAYS OF WEEK IN
ATTENDANCE
AM
PM
TIME
PM
TIME
LEAVES
CENTER
RETURNS TO
CENTER
FIRST CHILD
_____________________________
NAME:
BREAKFAST
A.M SNACK
LUNCH
P.M SNACK
SUPPER
EVENING SNACK
MONDAY
Other:
Enrollment Date: Withdrawal Date:
YES NO I work multiple shifts & children may be in care different
days/hours
TUESDAY
BIRTH DATE:
WEDNESDAY
THURSDAY
AGE:
FRIDAY
fd Saturday Sunday
SIGNATURE
___________________________________ _____________________ ___________________________________
Signature of Parent or Guardian DATE Telephone Number of Parent/Guardian
CHILD CARE REPRESENTATIVE
_______________________________________ ________________________
Name of Representative/Signature DATE
The effective date can be made retroactive back to the first day the child participates in the CACFP as long as it occurs in the same month this form is received.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and
employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability,
age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language,
etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact
USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information
requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW Washington,
D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: [email protected].
This institution is an equal opportunity provider