Agreement Number:Child and Adult Care Food Program Enrollment Agreement • March 28th, 2022
Your day care facility participates in the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP). The enrolled participant will receive nutritious meals and snacks at no cost to you. CACFP needs verification of enrollment for each participant in this facility . Please fill out the parent/guardian section of this form, sign it and return it to the above facility/provider. Provide information for one participant per section. (In order for the institution to receive reimbursement for meals served/claimed, this form must be completed for each enrolled participant annually.)
Institution Name: Lejeune-New River Child and Youth Program Agreement Number: 7422Child and Adult Care Food Program Enrollment Agreement • January 7th, 2016
Participant’s Name: Date of Birth: Typical Days of Care: Mon Tues Wed Thurs Fri Sat Sun Typical Hours of Care: Arrival Time AM PM Departure Time AM PM(use military time or mark AM/PM) Meals Normally Breakfast AM Snack Lunch PM Snack Supper Evening SnackEaten in Child Care: If participant is an infant (0-11 months), please complete this box. Check all applicable choice(s) below:Facility/Provider offers Specify Name formula for infants through the CACFP. It is your choice whether or not to use this formula based on your infant’s needs. Baby foods provided by the facility must be in compliance with the infant meal pattern as required by 7CFP 226.20.I will use the formula offered by this facility/provider, and I will prepare ready to fee bottles for my infant. I will not use the formula offered by this facility/provider.If not, which formula will you send in ready-to-feed bottles for your infant? If the formula you provide is a special formula, a medical statement must be sub
