Child Enrollment Form

IDOE/CACFP Name of Institution: Community Action Program of Evansville Sponsor ID Number: 1820162
June 2019 Name of Facility:

Child's Name: Date of Birth:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Please enter the normal hours your child is in care on the specific days of care
Please select the meals your child normally receives while in care
Will your school-age child be in attendance outside of the regular hours indicated above (snow days, school breaks, etc.)?

FOR INFANTS ONLY: All facilities must offer infant formula and meals / snacks to infants in care during meal service times

Infant Formula

This facility will provide the following iron-fortified infant formula:

Accept or Decline:

Provide name or parent-provided formula:

Infant Meals and Snacks

Accept or Decline:

This information is required by CACFP federal regulations at §226.15 (e)(2) and (3) for each enrolled participant, and must be updated annually.

Parent / Guardian Phone Number:

This institution is an equal opportunity provider.

Leave this empty:

Signature arrow

Signature Certificate
Document name: Child Enrollment Form
lock iconUnique Document ID: adc7ef69c9393f597290f4f2ecbad94de7f21730
Timestamp Audit
April 15, 2021 10:31 am CDTChild Enrollment Form Uploaded by Joe Massaro - IP