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 DAYS OF WEEK IN ATTENDANCE TIMES CHI LD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER FIRST CHILD MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours Other: Enrollment Date: Withdrawal Date: BIRTH DATE AGE FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER SECOND CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours Other: Enrollment Date: Withdrawal Date: BIRTH DATE AGE FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER THIRD CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours Other: Enrollment Date: Withdrawal Date: BIRTH DATE AGE Signature Signature of Parent or Guardian Date Telephone Number of Parent or Guardian CHILD CARE REPRESENTATIVE USE ONLY: 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. ************************************************************************************************************
Appears in 2 contracts
Samples: www.brooklinesprouts.com, s3.amazonaws.com
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 DAYS OF WEEK IN ATTENDANCE TIMES CHI LD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER FIRST CHILD MONDAY TUESDAY NAME WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours BREAKFAST THURSDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE FRIDAY LUNCH SATURDAY P.M. SNACK AGE SUNDAY SUPPER EVENING SNACK FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER SECOND CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK MONDAY NAME TUESDAY Yes No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours BREAKFAST WEDNESDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE THURSDAY LUNCH FRIDAY P.M. SNACK AGE SATURDAY SUPPER SUNDAY EVENING SNACK FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER THIRD CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK MONDAY NAME TUESDAY Yes No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours BREAKFAST WEDNESDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE THURSDAY LUNCH FRIDAY P.M. SNACK AGE SATURDAY SUPPER SUNDAY EVENING SNACK Signature Signature of Parent or Guardian Date Telephone Number of Parent or Guardian CHILD CARE REPRESENTATIVE USE ONLY: 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. ************************************************************************************************************
Appears in 2 contracts
Samples: www.greentreeselc.com, s3.amazonaws.com
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 DAYS OF WEEK IN ATTENDANCE TIMES CHI LD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER FIRST CHILD MONDAY TUESDAY NAME WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours BREAKFAST THURSDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE FRIDAY LUNCH SATURDAY P.M. SNACK AGE SUNDAY SUPPER EVENING SNACK FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER SECOND CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK MONDAY NAME TUESDAY Yes No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours BREAKFAST WEDNESDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE THURSDAY LUNCH FRIDAY P.M. SNACK AGE SATURDAY SUPPER SUNDAY EVENING SNACK FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER THIRD CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK MONDAY NAME TUESDAY Yes No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours BREAKFAST WEDNESDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE THURSDAY LUNCH FRIDAY P.M. SNACK AGE SATURDAY SUPPER SUNDAY EVENING SNACK Signature Signature of Parent or Guardian Date Telephone Number of Parent or Guardian CHILD CARE REPRESENTATIVE USE ONLY: 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. ************************************************************************************************************* The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at xxxx://xxx.xxxx.xxxx.xxx/complaint_filing_cust.html, or at any USDA office, or call (000) 000-0000 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 0000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000-9410, by fax (000) 000-0000 or email at xxxxxxx.xxxxxx@xxxx.xxx. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (000)000-0000; or (000) 000-0000 (Spanish).
Appears in 1 contract
Samples: creativelearningcentereaston.com
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 DAYS OF WEEK IN ATTENDANCE TIMES CHI LD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER FIRST CHILD MONDAY TUESDAY NAME WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours BREAKFAST THURSDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE FRIDAY LUNCH SATURDAY P.M. SNACK AGE SUNDAY SUPPER EVENING SNACK FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER SECOND CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK MONDAY NAME TUESDAY Yes No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours BREAKFAST WEDNESDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE THURSDAY LUNCH FRIDAY P.M. SNACK AGE SATURDAY SUPPER SUNDAY EVENING SNACK FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER THIRD CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK MONDAY NAME TUESDAY Yes No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours BREAKFAST WEDNESDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE THURSDAY LUNCH FRIDAY P.M. SNACK AGE SATURDAY SUPPER SUNDAY EVENING SNACK Signature 2/1/2022 Signature of Parent or Guardian Date Telephone Number of Parent or Guardian CHILD CARE REPRESENTATIVE USE ONLY: Name of Representative/Signature 2/1/2022 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. ************************************************************************************************************
Appears in 1 contract
Samples: foundationslc.com
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 requlations require all parents and guardians to complete a CACFP Annual Enrollment Form when enrolling their child(renchild (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 Age) DAYS OF WEEK IN ATTENDANCE TIMES CHI LD CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME TIMES CHILD ATTENDS SCHOOL AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER FIRST CHILD q MONDAY q TUESDAY q WEDNESDAY q THURSDAY q FRIDAY q SATURDAY q SUNDAY q BREAKFAST q A.M. SNACK q LUNCH q P.M. SNACK q SUPPER q EVENING SNACK NAME q Yes q No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours Other: Enrollment Date: Withdrawal Date: BIRTH DATE AGE FULL NAME OF ENROLLED CHILD (Include Birth Date/Age Age) DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME TIMES CHILD ATTENDS SCHOOL q Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER SECOND CHILD q Same as Above q MONDAY q TUESDAY q WEDNESDAY q THURSDAY q FRIDAY q SATURDAY q SUNDAY q Same Meals as Above q BREAKFAST q A.M. SNACK q LUNCH q P.M. SNACK q SUPPER q EVENING SNACK NAME q Yes q No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours Other: Enrollment Date: Withdrawal Date: BIRTH DATE AGE FULL NAME OF ENROLLED CHILD (Include Birth Date/Age Age) DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME TIMES CHILD ATTENDS SCHOOL q Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER THIRD CHILD q Same as Above q MONDAY q TUESDAY q WEDNESDAY q THURSDAY q FRIDAY q SATURDAY q SUNDAY q Same Meals as Above q BREAKFAST q A.M. SNACK q LUNCH q P.M. SNACK q SUPPER q EVENING SNACK NAME q Yes q No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours NAME Other: Enrollment Date: Withdrawal Date: BIRTH DATE AGE Signature Signature of Parent or Guardian Date Telephone Number of Parent or Guardian CHILD CARE REPRESENTATIVE USE ONLY: 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. ************************************************************************************************************
Appears in 1 contract
Samples: www.ccresourcesinc.org
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 DAYS OF WEEK IN ATTENDANCE TIMES CHI LD CHIL D NORMALLY ATTENDS DURING WEEK WE EK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER FIRST CHILD MONDAY TUESDAY X 7:00 X 4:30 NAME Xxxxxx Xxxxxxxx WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours BREAKFAST A.M. SNACK Other: BIRTH DATE 10/10/2014 FRIDAY SATURDAY SUNDAY Enrollment Date: 10/23/2018 Withdrawal Date: BIRTH DATE LUNCH P.M. SNACK SUPPER EVENING SNACK AGE 4 years old FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER SECOND CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Xxxxxxx Xxxxxxxx Yes No I work multiple shifts and child(xxxchild(ren) may be in care different days/hours Other: BIRTH DATE 8/26/2016 THURSDAY FRIDAY SATURDAY SUNDAY Enrollment Date: 10/23/2018 Withdrawal Date: BIRTH DATE LUNCH P.M. SNACK SUPPER EVENING SNACK AGE 2 years old FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER THIRD CHILD x Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Xxxx Xxxxxxxx Yes No I work multiple shifts and child(xxx) may be in care different days/hours Other: BIRTH DATE 11/23/2017 THURSDAY FRIDAY SATURDAY SUNDAY Enrollment Date: 10/23/2018 Withdrawal Date: BIRTH DATE LUNCH P.M. SNACK SUPPER EVENING SNACK AGE 11 months old Signature Xxxxx Xxxxxxxx 000-000-0000 Signature of Parent or Guardian Date Telephone Number of Parent or Guardian CHILD CARE REPRESENTATIVE USE ONLY: 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. ************************************************************************************************************* The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at xxxx://xxx.xxxx.xxxx.xxx/complaint_filing_cust.html, or at any USDA office, or call (000) 000-0000 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 0000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000-9410, by fax (000) 000-0000 or email at xxxxxxx.xxxxxx@xxxx.xxx. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (000)000-0000; or (000) 000-0000 (Spanish).
Appears in 1 contract
Samples: childnutritiontoolbox.com
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 DAYS OF WEEK IN ATTENDANCE TIMES CHI LD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER FIRST CHILD MONDAY TUESDAY NAME WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours BREAKFAST THURSDAY Other: Enrollment Date: Withdrawal Date: A.M. SNACK BIRTH DATE AGE FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER SECOND CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY LUNCH SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK AGE SUNDAY SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours Other: Enrollment Date: Withdrawal Date: BIRTH DATE AGE FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER THIRD CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours Other: Enrollment Date: Withdrawal Date: BIRTH DATE AGE Signature Signature of Parent or Guardian Date Telephone Number of Parent or Guardian CHILD CARE REPRESENTATIVE USE ONLY: 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. ************************************************************************************************************.
Appears in 1 contract
Samples: childnutritiontoolbox.com
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 DAYS OF WEEK IN ATTENDANCE TIMES CHI LD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER FIRST CHILD MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY X 8:30 X 5:30 BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Xxxxxxx Xxxxxxxxx Yes No I work multiple shifts and child(xxx) may be in care different days/hours Other: Enrollment Date: 10/23/2018 Withdrawal Date: BIRTH DATE 9/28/2015 AGE 3 years FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER SECOND CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Xxxxxxxxx Xxxxxxxxx Yes No I work multiple shifts and child(xxx) may be in care different days/hours Other: Enrollment Date: 10/23/2018 Withdrawal Date: BIRTH DATE 8/21/2014 AGE 4 years FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER THIRD CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY 11:30 4:00 Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Xxxxx Xxxxxxxxx Yes No I work multiple shifts and child(xxx) may be in care different days/hours Other: Enrollment Date: 10/23/2018 Withdrawal Date: BIRTH DATE 7/8/2013 AGE 5 years Signature Xxxxx Xxxxxxxxx 10/23/0000 000-000-0000 Signature of Parent or Guardian Date Telephone Number of Parent or Guardian CHILD CARE REPRESENTATIVE USE ONLY: 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. ************************************************************************************************************* The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at xxxx://xxx.xxxx.xxxx.xxx/complaint_filing_cust.html, or at any USDA office, or call (000) 000-0000 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 0000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000-9410, by fax (000) 000-0000 or email at xxxxxxx.xxxxxx@xxxx.xxx. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (000)000-0000; or (000) 000-0000 (Spanish).
Appears in 1 contract
Samples: childnutritiontoolbox.com
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 Including Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHI LD CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-TIME IN TIME OUT TIME CHILD ATTENDS SCHOOL AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER FIRST CHILD ❏MONDAY ❏TUESDAY ❏WEDNESDAY ❏THURSDAY ❏FRIDAY ❏SATURDAY ❏SUNDAY ❏BREAKFAST A.M. ❏AM SNACK ❏LUNCH P.M. ❏PM SNACK ❏SUPPER ❏EVENING SNACK NAME Yes No yes no I work multiple shifts and child(xxx) may be in care different days/hours hours. BIRTH DATE Other: AGE Enrollment Date: Withdrawal Date: BIRTH DATE AGE FULL NAME OF ENROLLED CHILD (Include Including Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-TIME IN TIME OUT TIME CHILD ATTENDS SCHOOL ❏Same Times as As Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER SECOND CHILD ❏Same as Above above ❏MONDAY ❏TUESDAY ❏WEDNESDAY ❏THURSDAY ❏FRIDAY ❏SATURDAY ❏SUNDAY ❏Same Meals as Above above ❏BREAKFAST A.M. ❏AM SNACK ❏LUNCH P.M. ❏PM SNACK ❏SUPPER ❏EVENING SNACK NAME Yes No yes no I work multiple shifts and child(xxx) may be in care different days/hours hours. BIRTH DATE Other: AGE Enrollment Date: Withdrawal Date: BIRTH DATE AGE FULL NAME OF ENROLLED CHILD (Include Birth Date/Age DAYS OF WEEK IN ATTENDANCE TIMES CHILD NORMALLY ATTENDS DURING WEEK MEALS RECEIVED TIME-IN TIME OUT TIME CHILD ATTENDS SCHOOL Same Times as Above AM PM TIME AM PM TIME LEAVES CENTER RETURNS TO CENTER THIRD CHILD Same as Above MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY Same Meals as Above BREAKFAST A.M. SNACK LUNCH P.M. SNACK SUPPER EVENING SNACK NAME Yes No I work multiple shifts and child(xxx) may be in care different days/hours OtherSignature: Enrollment Date: Withdrawal Date: BIRTH DATE AGE Signature Signature of Parent or Parent/Guardian Date Telephone Number of Parent or Parent/Guardian CHILD CARE REPRESENTATIVE USE ONLY: Name and Signature of Representative/Signature Representative 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 (000) 000-0000. 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: xxxx://xxx.xxxx.xxxx.xxx/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 (000) 000-0000. Submit your completed form or letter to USDA by: Mail: U.S. Department of Agriculture Fax: (000) 000-0000 Email: xxxxxxx.xxxxxx@xxxx.xxx Office of the Assistant Secretary for Civil Rights
Appears in 1 contract
Samples: parentinfantcenter.org
