CACFP-ENROLLMENT NEW YORK STATE DEPARTMENT OF HEALTH Child and Adult Care Food ProgramChild Enrollment Form for Day Care HomesParent or Guardian Completes FormName of Day Care or Owner/Operator On-Site Provider (If different) Child's Name Child# DOB Female Male Child's Name Child# DOB Female Male Child(ren)'s Ethnic Information /Choose one option per child) Hispanic or Latino not Hispanic or Latino Child(ren)'s Racial Information /Choose one option per child) American Indian or Alaskan Native L] Asian Native Hawaiian or other Pacific Islander Black or African American Asian White Primary language spoken at home Check if any of these apply Provider's Resident Child Child is related to Provider child of Migrant Farm Worker Special Needs Foster Child HOURS/DAYS/MEALSTime Care Begins Hours : Minutes AM PM AM/PM Time Care Ends Hours : Minutes AM PM AM/PM Days child normally receives care Mon-Fri OR Mon Tues Wed Thurs Fri Sat Sun Meals Child normally receives in care Breakfast AM Snack Lunch PM Snack Supper LN Snack Holiday and/or Weekend Care Yes No Time Care Begins Hours : Minutes AM PM AM/PM Time Care End Hours : Minutes AM PM AM/PM Does child(ren) attend school Yes No Name of School Does child receive care on non -school days Yes No INFANT FEEDING STATEMENT — (must be completed for any child less than one year of age) The Parent wil supply breastmilk or formula The Parent will supply ALL infant's food The Provider will supply formula The Provider will supply infant's food CONTACT INFORMATION FOR PARENT/GUARDIAN - to be completed by Parent/GuardianParent/Guardian's Name Parent/Guardian's Name Home Phone Number Work/Cell Phone Number Parent/Guardian Signature Date MM slash DD slash YYYY For Sponsor Use OnlyDate Enrollment Begins MM slash DD slash YYYY Date Enrollment Expires MM slash DD slash YYYY Child Enrollment Approved INITIALSEmergency Placement PROVIDER NAMEUSDA is an equal opportunity provider and employer.
