Child Enrollment Form - Standard Child And Adult Care Food Program Page 2
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2Child Enrollment Form—Standard
Child and Adult Care Food Program
Dear Parents,
Your child care center participates in the United States Department of Agriculture’s (USDA) Child and Adult Care Food
Program (CACFP). This child care center receives federal cash assistance to serve healthy meals to your children. Good
nutrition today means a stronger tomorrow! Meals served here must meet nutrition requirements established by USDA’s
CACFP. In order to participate, your center has agreed to follow USDA guidelines. In an effort to assess that these
requirements are being met, USDA’s CACFP requires centers to annually collect the enrollment information listed below.
Please complete the form and return it to your child care center.
Name of the Child Care Center: Love to Grow On
Beginning Date of Child Care:
Child’s First Name
Child’s Last Name
Child’s Date of Birth
Enter the normal hours your child is in care. For example, 7:30 AM – 5:00
______________ to ______________
PM or for a split schedule, 7:30 AM – 9:00 AM and 12:30 PM – 5:00 PM.
______________ to ______________
Check the days your child normally attends:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Check the meals your child normally receives while in care:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Night Snack
Beginning Date of Child Care:
Child’s First Name
Child’s Last Name
Child’s Date of Birth
Enter the normal hours your child is in care. For example, 7:30 AM – 5:00
______________ to ______________
PM or for a split schedule, 7:30 AM – 9:00 AM and 12:30 PM – 5:00 PM.
______________ to ______________
Check the days your child normally attends:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Check the meals your child normally receives while in care:
Breakfast
AM Snack
Lunch
PM Snack
Supper
Night Snack
If there are other children in care, please complete additional forms as needed.
Parent’s Signature
Date Signed
(form must be completed annually)
Parent’s Name (please print):
Home Phone:
Work Phone:
Mailing Address:
City:
State:
Zip:
For questions please contact:
Sponsoring Organization:
State Contact Information:
[insert Name, Address, Phone]
Minnesota Department of Education- Food and Nutrition Service
1500 Highway 36 West, Roseville, MN 55113
651-582-8526 or 1-800-366-8922 -
mde.fns@state.mn.us
Nondiscrimination statement: The U.S. Department of Agriculture (USDA) 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 , or at any USDA office, or call (866) 632-9992 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, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by
fax (202) 690-7442 or email at program.intake@usda.gov.
Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint please contact
USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
Persons with disabilities who wish to file a program complaint, please see information above on how to contact us by mail directly or by
email. If you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please
contact USDA's TARGET Center at (202) 720-2600 (voice and TDD).
USDA is an equal opportunity provider and employer.
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