"DEPARTMENT OF DEFENSE CHILD DEVELOPMENT PROGRAM REQUEST FOR CARE RECORD"
DEPARTMENT OF DEFENSE CHILD DEVELOPMENT PROGRAM REQUEST FOR CARE RECORD PRIVACY ACT STATEMENT AUTHORITY: PL 101-89 Sec. 1507; EO 9397. ROUTINE USE(S): None. PRINCIPAL PURPOSE(S): To collect applicant information for Child DISCLOSURE: Voluntary; however, failure to furnish requested Development Programs and place applicants on waiting lists for information will result in an incomplete request for care record and program services. Information compiled from applications is also possible loss of placement on Child Development Program waiting used to assist management determination of effectiveness of lists. present and projection of future program requirements. 1. DATE OF REQUEST (YYYYMMDD) 2. EXPIRATION DATE (YYYYMMDD) 3. FAMILY INFORMATION a. SPONSOR'S NAME (Last, First, Middle Initial) b. SPOUSE'S NAME (Last, First, Middle Initial) c. CHILD'S NAME (Last, First, Middle Initial) d. CHILD'S DATE OF BIRTH (YYYYMMDD) e. CHILD'S AGE f. HOME ADDRESS (Street, City, State, Zip Code) g. SPONSOR'S BRANCH OF SERVICE h. DUTY ORGANIZATION i. HOME TELEPHONE NUMBER (Include Area Code) j. DUTY TELEPHONE NUMBER (Include Area Code) k. SIBLING CARE (Complete a separate form and list name and date of birth for each child requiring care) (2) DATE OF BIRTH (2) DATE OF BIRTH (1) NAME (Last, First, Middle Initial) (YYYYMMDD) (1) NAME (Last, First, Middle Initial) (YYYYMMDD) 4. PROGRAM(S) DESIRED (X as applicable) 5. AGE GROUP (X one) a. FULL-DAY CARE e. FAMILY DAY CARE (FDC) a. INFANTS (0 - 12 months) b. PART-DAY CARE f. PART-DAY ENRICHMENT b. TODDLERS (13 - 35 months) c. SCHOOL-AGE g. DAY CAMP c. PRESCHOOL (3 - 5 years) d. SPECIAL NEEDS d. SCHOOL AGE (5+ years) 6. SPONSOR STATUS (X one) a. SINGLE MILITARY e. SINGLE DOD CIVILIAN i. MILITARY/UNEMPLOYED SPOUSE b. DUAL MILITARY f. RETIRED MILITARY j. MILITARY/OTHER THAN DOD SPOUSE c. MILITARY/DOD SPOUSE g. MILITARY RESERVE k. OTHER (Specify) d. DUAL DOD CIVILIANS h. NATIONAL GUARD 7. PRESENT CHILD CARE ARRANGEMENTS (X as applicable) a. FDC ON-INSTALLATION d. CIVILIAN CDC g. IN-HOME CARE b. FDC OFF-INSTALLATION e. MILITARY ALTERNATE CARE h. NO PRESENT CARE c. OTHER MILITARY CHILD f. NON-MILITARY ALTERNATE i. OTHER (Specify) DEVELOPMENT CENTER (CDC) CARE 8. GENERAL INFORMATION (X and complete as applicable) YES NO a. IF CHILD IS NOT PRESENTLY IN CARE, IS EMPLOYMENT YES NO c. IS CHILD ON OTHER MILITARY WAITING LIST? OF SPOUSE AWAITED? (If Yes, estimate average annual (If Yes, name installation) income lost) b. HAS CHILD BEEN IDENTIFIED FOR SPECIAL NEEDS d. CURRENT COST OF CARE PER WEEK (If child is currently in care) CARE? 9. UPDATE REQUIRED PER INSTRUCTIONS (For Office Use Only) (1) (2) (3) (4) (5) a. DATE CALLED (YYYYMMDD) b. DECLINED/ PLACED c. COMMENTS/ INITIALS d. PLACEMENT TIME (In months) DD FORM 2606, JUL 1998 (EG) PREVIOUS EDITION MAY BE USED. Designed using Perform Pro, WHS/DIOR, Jul 98 Reset MARINE CORPS COMMUNITY SERVICES, CHILDREN AND YOUTH PROGRAMS MARINE CORPS AIR STATION CHERRY POINT, NC Thank you for your interest in the Children and Youth Program (CYP). In order to participate in Child Development Programs, the following documentation must be submitted, completed in full, for each child : (*Designates forms found online at www.mccscherrypoint.com/youth.htm) _____ *Request for Child Care Record _____ *Registration Form _____ *Child Health Screening Form _____a current copy of the child’s up-to-date immunization records _____a doctor’s note of verification for any child with allergies and/or special needs, if noted on the Registration Form. (Special needs include, but are not limited to: asthma, ADD, ADHD, food allergies, seasonal allergies, etc) _____*Medication/Release of Liability Forms are required _____ LES and/or pay stubs: Proof of Income, verifying current income for sponsor and spouse. -------- * Discipline and Touch Policy _____ *Child and Adult Care Food Program Forms o *Participant Enrollment Form o Provision of Breast Milk or Infant Formulas and Provision of Baby Food (if applicable) Note: The following items will also be required, if applicable: _____For Dual/Single Military: a copy of your current Family Care Plan(s) _____For parents attending school full-time: school registration verification _____For those requesting an unborn child to be put on the Projected Care waiting list: confirmation of pregnancy _____For families requesting School Age Care (located in The Cherry Tree House): _____*Computer Lab/Internet User Agreement Form _____*After School Transportation; On and Off Air Station _____*Disciple Policy Once the required documentation has been completed, please return all forms and attachments to: Child Care Resource and Referral, located at The Cherry Tree House, Building 4415, on 4th Avenue. The Resource and Referral Office hours of operation are Monday through Friday, from 0730 – 1630. (252) 466-3595 / 5079 / 4120 / 5605 CHERRY POINT CHILDREN AND YOUTH PROGRAM REGISTRATION FORM OFFICE Program: Fee Category: USE ONLY Enrollment Date: Registration Date: CHILD’S FULL NAME: DOB: Please Indicate: Allergies/Special Needs: (Please be specific) M F Ethnicity: SPONSOR’S NAME: Rank/Rate: DOB: Squadron/Unit: Work Phone: Ethnicity: Email Address: Cell Phone: SPOUSE’S NAME: Rank/Rate: DOB: Work/School: Work Phone: Ethnicity: Email Address: Cell Phone: Home Address: City: State: Zip: Home Phone: I hereby authorize the following Emergency Contact Persons to be called in the event I cannot pick up my child for any reason: (minimum of 2 contacts are required, each available within 30 minutes of Cherry Point) Names Addresses Contact Numbers (Cell) 1. (Other) (Cell) 2. (Other) (Cell) 3. (Other) I hereby authorize any and all medical and hospital care and treatment to sustain life to my child, _________________________(child’s name) in the event of serious illness or injury in my absence. Sponsor/Spouse Signature: Date: FOR OFFICE USE ONLY FCP: SNERT: Health Screening YES NO Date: YES NO Date: Date: Children and Youth Program MCAS Cherry Point Parental Consent Form FIELD TRIP PERMISSION My child, _________________________________ , has permission to go on all walking (buggy) field trips surrounding the Child Development Center/Cherry Tree House. I understand that during fire evacuation and special events my child(ren) will be beyond the fenced areas of the facility. The United States Marine Corps will not be held liable. _____________________________________________________________ Parent/Guardian Signature Date PHOTOGRAPH PERMISSION I, the parent/legal guardian of ______________________________________ , a child participating in the Marine Corps Air Station (MCAS) Cherry Point Development Programs (CDP), which includes the School Age Care/Youth Programs located at The Cherry Tree House, hereby give the Marine Corps Community Services, MCAS Cherry Point, CDP, unlimited and unqualified authority to take, make, use, store, transmit, publish, disseminate, and reproduce the photographs, motion pictures, and digital video images of the above named child participating in the MCCS CDP sponsored programs/activities for Public Affairs effort and all related lawful purposes. _____________________________________________________________ Parent/Guardian Signature Date CCTV PRODEDURES (MCCSO 1754.1) This Order establishes procedures for the use of Closed Circuit Television (CCTV) in Marine Corps Community Services (MCCS) Child Development and Youth Centers, Marine Corps Air Station, Cherry Point. This Order provides that parents have primary responsibility for the health, safety, and well-being of their child(ren), and that parents shall have access to their children while at the CDC and CTH. In the spirit of providing unrestricted access to children, parents will be allowed to view their children interacting with other children and the staff by viewing their children through CCTV monitors. This is live real-time monitoring, not a video recorded account. I understand the above statement regarding CCTV viewing. _____________________________________________________________ Parent/Guardian Signature Date For Parents of Infants Only: INFANT SLEEP POSITION POLICY PARENT’S AGREEMENT In accordance with the American Medical Academy for Pediatrics, the National Institute of Child Health and Human Development, and the National Association for the Education of Young Children, the Children and Youth Program at Cherry Point support and adheres to the best practices to ensure infants are well cared for and safe. Research supports that the easiest practice to lower a baby’s risk of Sudden Infant Death Syndrome is to put the infan t on his/her back to sleep. We support the Back to Sleep Program and will place all young infants on their backs to sleep. I have read and understand, and agree to abide by the CTP Infant Sleep Position Policy. I understand that failure to comply with this policy will result in disenrollment. _____________________________________________________________ Parent/Guardian Signature Date CHILDREN AND YOUTH PROGRAM MCAS CHERRY POINT, NC CHILD HEALTH SCREENING MCO 1710.30E 2006 2. Health assessment, immunization records, child release and emergency information shall be maintained for all children enrolled and updated annually. Forms will be accessible only to authorized personnel. CHILD’S NAME: CHILD’S DOB SPONSOR’S NAME: HOME PHO NE# RANK: UNIT: WORK PHONE # A. IMMUNIZATIONS (ATTACH MOST CURRENT COPY OF IMMUNIZATION RECORD) B. Parents, please answer the following questions by circling the appropriate response: 1. At the last exam, was the child in good health? Y N 2. Has there been a significant change in the child’s health since the last exam? Y N 3. Has the child had prior hospitalizations, surgeries, significant illnesses, injuries or medical problems? Y N 4. Does the child have a medical condition requiring special care or attention? Y N List allergies, sensitivities, etc.: ___________________________________________________ 5. Does the child exhibit any of the following: a. Developmental delays? Y N b. Hyperactivity? Y N c. Bedwetting? Y N d. Potty training problems? Y N 6. Is your child receiving medication on a daily or regular basis? Y N If yes, indicate medication(s ) being given: ______________________________________ 7. Has your child had chicken pox? If yes, indicate mo/yr _____________________ Y N I Certify that my child is fr ee from obvious illness and is in good health. ______________________________ ________ PARENT SIGNATURE DATE C. Medical Provider’s Comments: This child has been screened by a medical provider and was found free of infections/contagious diseases. Yes No This child’s immunization record was screened and is up-to-date. Yes No This child can fully participate in Child Development Programs. Yes No 1. Please list any diagnosis, special needs, allergies, or 2. List any special accommodations needed: other sensitivities: (If none, please indicate NA.) (If none needed, please indicate NA) Medical Provider’s Signature Name of Medical Facility: Date of Most Recent Health Screening: _____/____/_____ Revised 8-2009 Marine Corps Community Services Children and Youth Program RELEASE FROM LIABILITY TAKING OF TEMPERATURES IN CHILDREN AND YOUTH PROGRAMS I ____________________________, the parent/guardian of _____________________________ understand that neither Marine Corps nor Navy policies require the taking of children’s temperatures to determine illness while enrolled for care at a military child care facility. I further understand that Children and Youth Personnel take temperatures only as courtesy to the children’s parents or guardians, and that a staff member will always ensure a child’s parent or guardian is contacted whenever, in that staff member’s opinion, a child “looks or acts sick.” I also understand that it will then be my responsibility to decide whether further evaluation and diagnosis by an authorized medical provider is warranted for my child. I further understand that Children and Youth Personnel ARE NOT TRAINED MEDICAL PROVIDERS and therefore, may misreport a child’s temperature due to misreading or misuse of the thermometer, or by using a defective thermometer. I also understand that injury or death could result to my child should I fail to seek medical evaluation based upon an erroneous temperature reading reported to by a staff member. Consequently, based upon my understanding of the risks involved in relying on bodily temperature readings furnished by Children and Youth Personnel, I hereby agree to release and hold harmless the United States Government, including the U. S. Marine Corps, Marine Corps Community Services (MCCS), Children and Youth Program (CYP), their offices, employees, agents, personnel, successors and assigns, from any and all claims, damages, liabilities, losses, injuries, deaths, and costs and expenses including attorney’s fees, and costs of suits arising out of or claimed on account of “courtesy temperature checks” furnished by staff members to assist in determining whether my child should receive child care or stay at home due to illness. ______________________________________________ ____________________________ Signature of Parent or Guardian Date ______________________________________________ ____________________________ Witness Date Marine Corps Community Services Children and Youth Programs DISCIPLINE AND TOUCH POLICY CHILD GUIDANCE AND DISCIPLINE POLICY Our goal is to promote self-control and appropriate social behavior in children/youth. We use positive methods to encourage development of these behaviors. Positive guidance helps children learn what is acceptable and what is not and helps children learn to make their own decisions. Childcare providers set behavior limits based on positive guidance and redirection as they focus on teaching rather then punishing. Aggressive behaviors are most often present when children lack the skills to cope with frustrating situations and are to be handled by validating the child’s feelings and/or redirecting the child to another activity. Time out should be used appropriately. Time out should only be used as a last resort, and only if the child is hurting him/himself, hurting others, or destroying property. Verbal abuse (including yelling or raised voices, threats, and derogatory remarks) and any type of physical punishment (such as squeezing to cause pain, jerking or pulling a child, slapping, hitting, restricting a child’s movement or placing a child in an isolated/confined space) are all forbidden and are grounds for immediate dismissal. Withholding or forcing meals, snacks, or naps are also forbidden. Our guidance strategies include: Use of clear directions Communication of age appropriate positive expectations/consequences Modeling appropriate verbal responses to conflicts Positive reinforcement Listening to the child Avoiding labeling of children Providing challenging activities or redirecting to alternate activities Ignoring behavior when appropriate to do so TOUCH POLICY Physical contact is important for a child’s development. A child/youth’s self-esteem grows when they are cared for in a loving manner. Holding hands, a pat on the back, a reassuring hug (lasting 3 seconds or less), and for younger children, a lap to sit on, and a reassuring back rub at nap time, are all nurturing gestures. These expressions of affection are natural for adults who work with children. INAPPROPRIATE TOUCHING IS GROUNDS FOR IMMEDIATE DISMISSAL FOR ANY STAFF MEMBER. Some obvious examples of inappropriate touching are: Shoving Pinching Squeezing Corporal punishment Head and/or arm twisting Biting Fondling DISCIPLINE OF A CHILD BY A PARENT WHILE ON CDC/CTH PREMISES At no time will a parent or guardian discipline a child by striking, shaking, or any other form of physical punishment while on the premises of the Child Development Center or The Cherry Tree House to include the playgrounds, parking lots, and surrounding grounds. Violation of such prohibition may result in disenrollment of the child (ren) from the program. REPORTING OF CHILD ABUSE AND NEGLECT When child abuse or neglect is suspected, Child Development Center (CDC) or Cherry Tree House (CTH) staff is required to report the suspected abuse/neglect immediately (same day) to the appropriate manager on duty. The center manager will immediately (same day) notify the Family Advocacy Program located within Marine and Family Services Building 232, of the suspected abuse/neglect case. A written report will be forwarded to the Family Advocacy Program Manager immediately (same day) concerning the facts surrounding the suspected abuse/neglect case. The Children and Youth Program Administrator will be contacted concurrently. The center manager will inform involved staff members of case status within 24 hours . NO CHILD IS TO BE LEFT UNATTENDED AT ANY TIME. IF YOU COME UPON A CHILD WHO HAS BEEN LEFT UNATTENDED, YOU ARE TO REPORT THIS TO THE DIRECTOR/ASSISTANT DIRECTOR IMMEDIATELY. I have read and understand the Cherry Point Children and Youth Programs Child Abuse and Discipline policies, to include the prohibition against physical punishment of children by parents or guardians while on the premises of the CDC and agree to abide by the policies and regulations contained therein. I understand that violation of the prohibition against physical punishment by parent or guardians may result in disenrollment of any child (ren) from the Child Development Center. Sponsor Printed Name__________________________________________________________ Sponsor’s Signature _________________________________________Date ______________ Spouse’s Printed Name__________________________________________________________ Spouse’s Signature _________________________________________Date________________ This document will be maintained in the child’s official folder. DoD Hotline: 1-800-336-4592 Cherry Point Family Advocacy: 252-466-4401 North Carolina Department of Health and Human Services Women’s and Children’s Health CHILD AND ADULT CARE FOOD PROGRAM CHILD ELIGIBILITY APPLICATION 1. PRINT THE PARTICIPANT’S NAME AND DATE OF BIRTH: NAME OF INSTITUTION: ________________________ First Name Last Name Date of Birth FACILITY NAME: _______________________________ First Name Last Name Date of Birth AGREEMENT NUMBER: ___________________________ First Name Last Name Date of Birth 2. FOOD STAMP, TANF or FDPIR : If the household currently receives FOOD STAMP, TANF or FDPIR benefits give the case number. Yes, we receive food stamps, TANF or FDPIR benefits. Case number is: Food Stamp # TANF # FDPIR # __________________________ If yes, and you have provided the case number, DO NOT complete #3 and #4. Complete #5(voluntary) and #6. If a child is a member of a food stamp or FDPIR household or TANF assistance unit, the child is automatically eligible to receive free Program meal benefits, subject to the completion of the application. 3. IS THIS A FOSTER CHILD? Yes No. If yes, give the child's income $ and DO NOT complete #4. Complete #5. A separate application must be completed for each foster child. In certain cases, foster children are eligible for free and reduced-price meals regardless of household income. 4. HOUSEHOLD MEMBERS MONTHLY INCOME: List all others living in your household, DO NOT include participant listed above. List all gross income (before deductions) received last month. If you did not give a food stamp, TANF or FDPIR case number or if this is not a foster child, you must complete the income information. Monthly Monthly Monthly Public Monthly Wages Social Assistance/ Retirement Monthly Names of all Other Household Members Salaries Security Child Support Pensions Other Earnings Earnings Earnings Earnings $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 5. ETHNIC IDENTITY: (Please check one). Hispanic or Latino Not Hispanic or Latino RACE OF PARTICIPANT: (Please check one or more). White Black or African American American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander 6. SIGNATURE AND SOCIAL SECURITY NUMBER: I certify that all of the above information is true and correct and that all income is reported. I understand that this information is being given for the receipt of federal funds; that Program officials may verify the information on the application and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal criminal laws. _____________________________________ Signature of Adult Household Member (Required) Date: Social Security Number ((Required (all 9 digits) for households qualifying by income) _____ ________ ____________ Printed Name Home Telephone # Work Telephone # __________________________________________________________________________________________________ Address City Zip Code The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but it you do not, we cannot approve your child for free or reduced price meals. You must include the social security number of the adult household member who signs the application. The social security number is not required when your apply on behalf of a foster child or you list a Food Stamp, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number for your child or other FDPIR identifier or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals and for administration and enforcement of the Program. If a child is a Head Start participant, the child is automatically eligible to receive free Program meal benefits, subject to submission by Head Start officials of a Head Start statement of income eligibility or income eligibility documentation. For Institution To be classified and completed by institution/sponsor For state use only: TOTAL HOUSEHOLD SIZE TOTAL HOUSEHOLD MONTHLY INCOME $ _____________ Verified by:_____________________ Date:_________ Approved: Free Reduced Denied Verified classification: Free Reduced Denied Reason for denial: Income too high Incomplete application Other Reason for change in classification: Withdrew on (Date): ______________ Signature of Eligibility Official Date CAC 11 (06/09) Nutrition Services PARENT GUARDIAN/HOUSEHOLD LETTER FOR NON-PRICING INSTITUTIONS CHILD AND ADULT CARE FOOD PROGRAM Dear Parent or Guardian, Please help us comply with the federal requirement mandating the annual submission of Program Eligibility Application (CAC 11). This application will be used only for eligibility determination, placed in our files and treated as confidential information. In order for participants and the day care center to be considered eligible for program benefits, an adult household member must complete the Program Eligibility Application for each participant enrolled in the center as soon as possible, sign, date and return it to the day care center. Completion of the application is not mandatory unless you wish to be considered for eligibility as a free or reduced price participant. If you currently receive food stamps, Temporary Aid to Needy Families (TANF) or Food Distribution Program on Indian Reservations (FDPIR), you are not required to list household income. You may give your food stamp, TANF or FDPIR case number, sign, date and return the application. If a child is a member of a food stamp or FDPIR household or is a TANF recipient, the child is automatically eligible to receive free Program meal benefits, subject to completion of the application. You should also note that if you have a foster child the day care center may be eligible for program benefits for the foster child regardless of the income of your household. Please contact the institution for further instructions. You should list the name of everyone who lives in your household, including all children, parents, grandparents and other relatives. The Department of Agriculture defines a household as a group of related or unrelated individuals (not residents of an institution or boarding house) who are living as one economic unit (i.e. sharing living expenses). The income which you report must be the total gross income, before deductions, received by all members of your household last month (i.e. wages, welfare or retirement etc). Military benefits received in cash, such as housing allowance for military households living off base and food or clothing allowance, must be considered as income. If you have a household member for whom last month’s income was higher or lower than usual, list that person’s expected average monthly income. Households with incomes less than or equal to the levels in the chart below, are eligible for free or reduced price meals. EFFECTIVE JULY 1, 2009 - JUNE 30, 2010 REDUCED GUIDELINES MONTHLY TWICE PER EVERY WEEKLY HOUSEHOLD YEARLY MONTH SIZE TWO WEEKS 1 20,036 1,670 835 771 386 2 26,955 2,247 1,124 1,037 519 3 33,874 2,823 1,412 1,303 652 4 40,793 3,400 1,700 1,569 785 5 47,712 3,976 1,988 1,836 918 6 54,631 4,553 2,277 2,102 1,051 7 61,550 5,130 2,565 2,368 1,184 8 68,469 5,706 2,853 2,634 1,317 For each +6,919 +577 +289 +267 +134 Household member add: You may submit a program eligibility application any time during the fiscal year. Participants having family members who become unemployed are eligible for free or reduced-price meals during the period of unemployment, provided that the loss of income causes the family’s income during the period of unemployment to be within the eligibility standards for those meals. In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer. DHHS CAC-11 (06/09) Nutrition Services CACFP ELIGIBILITY APPLICATION INSTRUCTIONS Please complete the Child and Adult Care Food Program Eligibility Applications using the instructions below. Sign the statement and return it to your child care center. PART 1-PARTICIPANT’S INFORMATION: Complete this part. Print the name(s) of the child enrolled in the center. PART 2-HOUSEHOLD GETTING FOOD STAMPS, TANF, OR FDPIR BENEFITS: Complete this PART and PART 6. (1) List your current food stamp, TANF, or FDPIR case identification number. (2) An adult household member must sign the statement in PART 6. PART 3-FOSTER CHILD (1) Indicate if child is a Foster Child. A separate application must be completed for each foster child. (2) If yes, do not complete PART 4. (3) An Adult household Member must sign the statement in PART 6. PART 4- HOUSEHOLD INCOME: Complete this PART and PART 6 (1) List the names of household members. (2) Write the amount of income (the amount before taxes or anything else is taken out), the frequency of income (i.e. weekly, every two weeks, twice a month, or monthly) received last month for each household member and where it came from, such as earnings, welfare, pensions and other income (refer to examples below for types of income to report). If any amount last month was less than usual, write the person’s usual income. (3) An adult household member must sign this income eligibility statement and give his/her social security number in PART 6. PART 5-RACIAL/ETHNIC IDENTITY: Complete the Ethnic/Racial identity question. PART 6-SIGNATURE AND SOCIAL SECURITY NUMBER: All households complete this PART. (1) All eligibility statements must have this signature of an adult household member; (2) The adult household member who signs the statement must include his/her full social security number. If he/she does not have a social security number, write “none”. If you listed a food stamp, TANF, or FDIR number a social security number is not needed. INCOME TO REPORT Earnings from Employment Pensions/Retirement/Social Security Other Income Wage/salaries/tips Pensions Disability benefits Strike benefits Supplemental security income Cash withdrawn from savings Retirement income Interest/dividends Unemployment compensation Veteran’s payments Income from estates/trusts/ Worker’s compensation Social security investments Net income from self-owned business or farm Regular contributions from persons not living in the Welfare/Child Support/Alimony Military Households household Public assistance payments All cash income, including military Net royalties/annuities/ Welfare payments housing/uniform allowances. Does net rental income Alimony/Child support payments not include “in-kind” benefits NOT Any other income paid in cash (base housing, clothing, food, medical care, etc.) Foster Child’s Income ONLY funds from welfare agency identified by category for personal use of child (clothing, school fees, etc.), funds from child’s family for personal use and earnings from other than occasional or part-time employment. DO NOT COUNT funds from welfare agency for shelter, care, etc. All programs of the United States Department of Agriculture are available to everyone with out regard to race, color, sex, national origin, age or disability. CAC 11 (06/09) Nutrition Services Child and Adult Care Food Program (CACFP) Participant Enrollment Form Institution Name: ______________________________________ Agreement Number: ___________ Facility/Provider Name:_________________________________ Dear Parent/Guardian, Your day care facility participates in the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP). CACFP needs verification of enrollment for each participant in this facility. Please complete the table below for all participants in your household that are enrolled at this facility. The information below should be completed by the parent or guardian. Please use the guides below the table to complete. Please sign and date this form below. Participant’s First Participant’s Last Normal/Typical Normal/Typical Days of Meals Normally Eaten Name Name Hours of Care Care (Circle all that apply) (Circle all that apply) ______ to ______ M T W TH F Sat Sun B AM L PM S LPM ______ to ______ M T W TH F Sat Sun B AM L PM S LPM ______ to ______ M T W TH F Sat Sun B AM L PM S LPM ______ to ______ M T W TH F Sat Sun B AM L PM S LPM ______ to ______ M T W TH F Sat Sun B AM L PM S LPM Guide: Normal hours of care: Please insert the usual arrival time and the usual departure time. Indicate a.m. or p.m. Normal days of care: Please circle the days of the week the participant(s) are usually in attendance at the facility. (M=Monday; T=Tuesday; W=Wednesday; TH= Thursday; F=Friday; Sat =Saturday; Sun=Sunday) Meals Normally Eaten – Please circle the meals the participant(s) usually eats at the facility. (B=Breakfast; AM=AM Snack; L=Lunch; PM=PM Snack; S=Supper; LPM=Late PM/Evening Snack Parent/Guardian Signature: ____________________________________ Date: _____________ Print Name: ___________________________________________ Address: _____________________________________________________________________ City: ___________________________________________ State: _____ Zip Code: _________ Home Telephone Number: ( ) ________________ Work Telephone Number: ( ) ________________ For Facility/Provider Use Only: Signature of Facility Representative/Provider: _______________________________________________ Date: ______________ Date the participant withdrew: ________________________ In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, 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 State Use Only: Complete: _______ Incomplete _______ Reason: ______________________ Verified by:__________________ Date:__________ DHHS CAC-Enrollment (1/09)