Cacfp Student Enrollment Form - Palestine Ymca
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1CACFP STUDENT ENROLLMENT FORM
CCS-1500
INSTRUCTIONS:
If data is incorrect in box, correct information on the right side.
Complete certification section before signing and dating form.
Data Currently On File
Parent's First Name:
Parent's Last Name:
Parent's Phone Number:
Student's First Name:
Student's Last Name:
/
/
Student's Birthdate:
Ethnic Identity:
Hispanic or Latino
Not Hispanic or Latino
(Mark only 1)
White
Black/African American
Am. Indian/Alaskan Native
Racial Identity:
(Mark 1 or more)
Asian
Native Hawaiian/Other Pacific Islander
Gender:
Male
Female
Enroll Date:
_____/_____/________
Days in Care:
Mon
Tues
Wed
Thur
Fri
Sat
Sun
Hours in Care:
From _________:__________ To _________:_________
Meal/Snacks Provided:
Brk
AMS
Lun
PMS
Sup
EVS
Times Child Attends School
Leaves _________:__________ Returns _________:_________
(school-age child only)
Parent Certification
I work multiple shifts and child may be in care different days/hours:
Yes
No
I certify the information on this form is true and correct to the best of my knowledge.
I certify that I have received access to WIC and CACFP literature within the last 12 months.
Signature of Parent
Date
People who are eligible to participate in the program must not be discriminated against because of race, color, national origin,
sex, age, or disability. Anyone who believes they have been discriminated against should immediately write to: USDA; Director,
Civil Rights Department, 1400 Independence Ave; SW; Washington D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382
(TTY) USDA is an equal opportunity provider and employer.
For Licensed Center Use Only:
Withdrawal Date: _____/_____/________
Re-Enroll Date:
_____/_____/________ Withdrawal Date: _____/_____/________
Classroom Assigned:
CACFP Effective Date
For CACFP Sponsor Use Only:
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