\ ,,,,.,, ,"'- {' Child and Adult Care Food Program, Child Enrollment Form, Agreement#4-07-39-428 Sponsoring Organization Lehigh Valley Children's Centers Center/Home: Address 1501 Lehigh Street, Suite 208 Address -.,- __ --'Allentown PA 18103 1-800-258-3737, or 610-820-5333 _ _ CHILD AND ADULT CARE FOOD PROGRAM I INFANT ENROLLMENT FORM This enrollment supplem9nt must be; completed for all infants in care at the time of enrollment to determine responsibility for providing infant formula as part of the phild and Adult Care Food Program (CACFP). Please have the parent sign and date tW0 forms. Send one to your sponsoring organization and keep the other as part of the infant's enrollment file.' I I Directions: I Infant Name: I I Date of Birthi Home/Center Site: I Home/Center will offer the following iron-fbrtified formula: PARENT CHOICE: (Please check one) I The Center/Home will furnish infant's'formula, -The Parent will furnish the iffant's forrulalbreast Indicate Type of Formula or BreaSJMilk I _ milk. ' I IF THE ABOVE TYPE OF IRON FORMU A DOES NOT MEET CACFP REQUIREMENTS, PLEASE A IT ACH A COpy OF THE PHYSICIAN'S ME ICAL STATEMENT RECOMMENDING THIS TYPE OF FORMULA Are there any special circumstances or. conditions indicated by the infant's physician? I As the parent of the above-named notice. child, I untlerstand that I may change my decision regarding furnishing infant formula with proper Parent's Signature Date Signature of Center Director/Home Provider Date CHILD CARE REPRESENTATIVE USE ONLY: Name of Representotive¥Signature The effective date can be made retroactive The U.S. Department natianalorigin, orientation, program Date back to the first day the c~ild participates oj Agriculture prahibits discrimf,·nation against its customers, age, disability, sex, gender identity, or al/ or part of an individual's in the CACFPas long as it occurs in the same month this form is received. employees, and applicants for employment on the bases of race, color, ligian, reprisal, and where applicable, political beliefs, marital status, familial ar parental status, sexual income is erived from any public assistance pragram, or protected genetic information in emptoyment or activity conducted or funded by the Department. If yau wish ta file a Civil Rights program complaint (No al/ prohibited of discrimination, l]!Jl2JL!www.ascr.usdSHlQy!coITJRlaintfilingcust.htl. containing ar in any \ al/ of the information requested in the for bases will apply to 01/programs complete and/or employment the USDA Program Discrimination Camplaint Farm, faund anline at or at any USDA office, or call (866) 632-9992 ta request the form. . Send your completed activities.) Yau may alsa write a letter complaint form ar letter ta us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, Individuals 1400 Independence Avenue, S. W., Wasqington, D.C. 20250-9410, by fax (202) 690-7442 or email ate!:Q9!am.intake@usda.9.QJ{. who are deaf, hard of hearing or have spepch disabilities may contact USDA through the Federal Relay Service at (800)877-8339; or (800) 845- 6136 (Spanish). USDA-is an equal opportunity provider and employer. ·r ~~,-~ ,.j ,-% .;!i Child and Adult Care Food Program Child Enrollment Form ""j•.-J :;. ~: .,;', Sponsoring Organization Lehigh Valley Children's Centers Address 1501 Lehigh Street, Suite 208 AllentownPA 18103 - Home Provider: Telephone r Address: I I I Home ENROLLMENT Address I Parent/Guardian: Agreement #300-39-428--0 1-800-258-3737,or610-820-5333 Work: WITHDRAWAL DATE- DATE- TIMES CHILD NORMALLY ATTENDS DURING WEEK DAY OF WEEK IN FULL NAME OF ENROLLED (Include TIME IN ATTENDANCE CHILD Birth Date/Age) Please Cheyk (v"") , TIME CHILDATIENDS SCHOOL I A M P TIME M MONDAY A M P TIME M : I THURSDAY I FRIDAY : : I Optional: Relationship Will to provider: additional - yes, School meals specrrv- please 0 D Asian I Day care be provided District 0 -- u::,naCK Elementary~ Yes SUPPER : EVENING SNACK -- D Native Hawaiian or Other Pacific Islander DOwn o No o Foster u::,upp Middle School High School _ - , I ENROLLMENT PM SNACK : DIWhite o Nephew/Niece Grandchild -,Luncn , LUNCH D Not Hispanic or Latino not in session? i u sreakrast - me meal: C school AM SNACK : : 0 I'\merican Indian or Alaska Native child when : : : i? Hispahic or Latino Mark one ethnic and racial identities Optional: Mark one more racial identities: DBlack or African American BREAKFAST : I SUNDAY RETURNS TO CENTER : : : SATURDAY GENDER D F D M LEAVES CENTER : TUESDAY AGE Please Check : WEDNESDAY BIRTH DATE MEALS RECEIVED (v"") TIMES VARY Please (v') if necessary DAYS VARY NAME (First Child) TIMEOUT WITHDRAJvAL DATE: DATE: TIMES CHILD NORMALLY ATTENDS DURING WEEK DAY OF WEEK IN TIME IN FULL NAME OF ENROlLED ATTENDANCE CHILD Please Check (v"") (Include TIME CHILDATIENDS SCHOOL A M DAYS VARY TUESDAY : WEDNESDA' THURSDAY Will additional If yes, please School meals specify District 0 the meal: LEAVES CENTER RETURNS TO CENTER : : : AM SNACK : : : : LUNCH : : : : PM SNACK FRIDAY : : : : SUPPER SATURDAY : : : : EVENING SUNDAY : : : o Hisp~nic or Latino 0 Asian when 0 TIME BREAKFAST Day care be provided P M : Mark one ethnic and racial identities to provider: A M child [] school Breakfast o Not Hispanic or Latino o White o Native Hawaiian C American Indian or Alaska Native o Nephew/Niece Grandchild s not in session? []Lunch 0 DSnack Elementary Middle Yes DOwn or Other Pacific Islander o Foster DNa DSupper School High School I Signature: Signature: Date: Date: JI1 I p pprop g V) Please Check : Optional: Mark one more racial identities: DBlack or African American Relationship TIME : GENDER 0 F D M Optional: p M MONDAY BIRTH DATE AGE MEALS RECEIVED TIMES VARY Please (v') if necessary Birth Date/Age) NAME (First Child) TIMEOUT / SNACK