SCHEDULE OF ACTIVITIES

East Side Location
Northeast Location
11720 Montana Ave. Bldg. B
El Paso, Texas 79936
(915) 849-9959 tel.
(915) 849-9622 fax
4525 Sun Valley Dr. Bldg. D
El Paso, Texas 79924
(915) 822-2264 tel.
(915) 822-2449 fax
corner of Montana & Saul Kleinfeld
corner of Sun Valley Dr. & US 54
www.mylittlefootsteps.com
[email protected]
SCHEDULE OF ACTIVITIES
Open Daycare Center
Free Play In Centers
Breakfast
Activities* (Please refer to the teacher’s lesson plans)
Lunch
Nap
Diapering and Clean Up
Snack
Activities* (Please refer to the teacher’s lesson plans)
Dinner
Activities
CLOSE
SUPPLIES NEEDED
Pre-School
1. Extra clothes
2. Wipes
3. Small blanket for nap time
4. Shot records & physician’s
statement
5. 16 qt cubbie with lid
6. Toothbrush & Toothpaste
5:00 am East / 5:30 am Northeast
5 a.m. – 7:30 a.m.
7:30 a.m. – 8:30 a.m.
8:30 a.m. – 10:30a.m.
10:30 – 11:30
12:00 p.m. – 2:00 p.m.
2:00 p.m. – 2:45 p.m.
2:45 p.m. – 3:15 p.m.
3:15 p.m. – 5:15 p.m.
5:15 p.m. – 6:15 p.m.
6:15 – 6:30 p.m.
6:30
Infants & Older Infants:
1. Diapers
2. Wipes
3. Clothes
4. Bibs
5. Pacifier (optional)
6. Bottles (4)
7. Formula if you will not be
using ours (Sam’s brand)
8. Shoes if they have started walking
9. Shot records & physician’s statement
10. 16 qt cubbie with lid
Toddlers:
1. Diapers/Pull Ups
2. Wipes
3. Toothbrush & Toothpaste
4. Clothes
5. Bibs
6. Small blanket for nap time
7. Shot records & physician’s statement
8. 16 qt cubbie with lid
Your tuition payment includes the following for all age
groups:
• All meals (we do not use gerbers. We steam and
puree our own fruits and vegetables)
• The use of the curriculum and materials needed
• Unlimited hours of care for full time enrollment
Little Footsteps does not offer credits or adjustments
to tuition payments due to absences, holidays,
vacation, or any other reason.
Half of your child’s weekly tuition is due to reserve
space during vacation/absences.
Texas Dept of Family
and Protective Services
Form 2935
Oct 2008 / Pg 1 of 3
ADMISSION INFORMATION
Operation Name
Director’s Name
Little Footsteps Daycare & Learning Center
Child’s Full Name
Blanca M. Gonzalez
Child’s Date of Birth
Child’s Home Telephone No.
Child’s Home Address
Date of Admission
Date of Withdrawal
Parent’s or Guardian’s Name
Address (if different from child’s address)
Mother’s Telephone No.
Mother's Place of Work
Father’s Telephone No.
Father's Place of Work
Give the name, address and phone number of person to call in case of an emergency if parents / guardian cannot be reached:
Relationship
I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons. Please list name &
telephone number for each. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.
CHECK ALL THAT APPLY:
1.
TRANSPORTATION:
I hereby
give
do not give
for emergency care
on field trips
to and from home
to and from school
my consent for my child to participate in Field Trips:
do not give
I hereby
give
Permission slips will be sent out for each field trip. No child will be allowed to attend without a completed permission slip.
2.
FIELD TRIPS:
3.
WATER ACTIVITIES:
I hereby
do not give
give
sprinkler play
4.
consent for my child to be transported and supervised by the
operation’s employees:
my consent for my child to participate in Water Activities:
splashing/wading pools
swimming pools
water table play
RECEIPT OF WRITTEN OPERATIONAL POLICIES AND ADMISSION AGREEMENT INCLUDING:
I acknowledge receipt of the facility’s operational policies including those for discipline and guidance.
5. My child will be present for the following meals:
Breakfast
Lunch
PM Snack
Supper
6. MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES (please circle):
Mon.
:
Tues. Wed. Thurs. Friday from ___________ a.m to ______________p.m.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------7. I am aware that this center is paperless with regard to my child's documentation. I will provide the center with updated email addresses that I
check regularly. My failure to read these emails does not mean that I did not receive them.
Mother's Email: ______________________________________________________________________
Father's Email: _______________________________________________________________________
AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:
Name of Physician:
Address:
Ph.#:
Name of Emergency Medical Care Facility:
Address:
Ph.#:
I give consent for the facility to secure any and all
necessary emergency medical care for my child.
Signature - Parent or Legal Guardian
List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations
during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be
aware of:
Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation
may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800)-514-0383 (TTY).
Signature – Parent or Legal Guardian
Date
Texas Dept of Family
and Protective Services
Form 2935
Oct 2008 / Pg 2 of 3
ADMISSION INFORMATION
SCHOOL AGE CHILDREN:
My child attends the following school:
Name of School and Address
School Ph.#
CHECK ALL THAT APPLY:
His / her immunization record is on file at the school and all
required immunizations and/or tuberculosis test are current.
Vision and Hearing screening records are also on file.
My child has permission to:
ride a bus, and/or
walk to and from school,
be released to the care of his/her
sibling(s) under 18 years old.
Name of sibling(s):
IMMUNIZATION RECORD:
I have provided the childcare operation with a copy of my child’s most current immunization record.
updated immunization record every time my child is immunized.
I agree to bring an
ADMISSION REQUIREMENT: If your child does not attend pre-kindergarten or school away from the child-care operation, one of the
following must be presented when your child is admitted to the child-care operation or within one week of admission.
I have brought a copy of a statement from my child's physician stating that he/she is able to attend daycare.
1.
List any behavioral problems your child has been diagnosed with or may be a cause for concern:
List any reasons for which your child may have been expelled from any other childcare facility:
2.
A signed and dated copy of a health care professional’s statement is attached.
Date
Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a
member of; I have attached a signed and dated affidavit stating this.
[ My child has been examined within the past year by a health care professional and is able to participate in the day care program.
Within 12 months of admission, I will obtain a health care professional’s signed statement and will submit it to the child-care operation.
Signature - Parent or Legal Guardian
VISION
R 20/ ________
L 20/ ________
SIGNATURE ____________________________________________
HEARING
Date
1000 Hz
PASS
FAIL
DATE _____________________________________
2000 Hz
4000 Hz
R
L
PASS
SIGNATURE ___________________________________________
FAIL
DATE ______________________________________
Signature – Parent or Legal Guardian
Date
MILITARY FAMILIES
Mother's Unit:
_________________ Commanding Officer:
Commanding Officer's Phone:
Father's Unit:
___________________________
_________________ Commanding Officer:
Commanding Officer's Phone:
__________
__________
___________________________
ADMISSION AGREEMENT
This agreement is made by and between Little Footsteps
Daycare and Learning Center (herein referred to as
“CenteU
and
_______________________________
(Parent/Guardian) whose child or children are being
enrolled at this Center.
ORIENTATION
1. The Center has provided me with an overview of the
following aspects:
Goals and Objectives, Policies and Procedures
Handbook, Center’s Vision and Mission, an
overall tour of the Center and it’s operation
2. A copy of the Minimum Standards is available at the
Center’s office, as established by the Texas
Department of Family Protective Services. Contact
phone number 915-834-5739 or www.dfps.state.tx.us
or the Hotline for abuse and neglect at 1-800-2525400.
GENERAL INFORMATION
1. Hours of operation are from 5:00 AM to 6:30 PM,
Monday through Friday.
2. Enrollment ages are from 0 to 12 years of age.
3. All Center’s personnel are certified with CPR and
First Aid, Shaken Baby Syndrome, and SIDS.
4. Parents are welcome to our Center at any time as
visitors.
5. Parent may contact the Director of the Center at any
time at (915) 256-0924 to discuss any relevant issues
concerning the child or any Center-related business.
6. We reserve the right to change the rules, add new
ones, or modify the terms at any time. Parent will be
given written notification of any such changes.
HEALTH POLICIES
1. The Center will provide First Aid to any injured child.
2. 911 will be called in case of a serious injury and
Parent will be notified immediately.
3. Parent hereby authorizes the Center and its staff to
provide and call for medical services and treatment.
4. Parent must provide the Center with current and upto-date immunization records of the child in care,
including, but not limited to, TB test, vision and
hearing screening, and a Physical Statement.
5. Medication will be administered only with a
physician’s prescription and a labeled medication
LITTLE FOOTSTEPS DAYCARE & LEARNING CENTER
with the child’s name on the label. Other forms to
sign will be provided.
ILLNESS AND EXCLUSION
A child with the following symptoms MAY NOT attend:
Temperature of 100.5°F; Chicken pox-like blisters;
Conjunctivitis/pink-eye; Persistent or excessive
cough; Diarrhea or Vomiting; Rash, Scabies
(crusted, wavy ridges and tunnels in the webs of
hands, fingers, wrists, and trunk), Ringworm, Head
lice or any other contagious symptom
Your child may return to the Center when all symptoms
have disappeared for at least 24 hours, and have not
returned.
A doctor’s note may be required for
readmission.
Parent must pick up a child showing any of the
symptoms described above. Parent must pick up the
child within 1 hour of the first call. If the child is not
picked up by then, the Center will make proper
arrangements for pick-up with the authorities for
alternate care. ALL CHARGES INCURRED BY
THESE ARRANGEMENTS WILL BE THE SOLE
RESPONSIBILITY OF THE PARENT.
HEALTH CHECK
Staff will conduct an initial health check-up every
morning. Proper documentation will be filed at the
Center. Parent has a right to review these documents.
NOTICE OF PEST CONTROL TREATMENT
This facility uses pesticides indoors. These will be
applied on Friday evenings after the facility is empty.
FEE SCHEDULE AND PAYMENT POLICY
1. Transportation is provided and your child is not at the
specified location.
2. A $5.00 charge will be assessed if Parent does not
notify Center on or before 2:00 PM not to pick-up
child.
3. Half of full payment will be charged in advance
according to time absent due to vacation to reserve
time slot.
4. A fee of $1.00 per minute per child will be charged
for every late pick-up from the Center.
5. A fee of $35.00 will be charged for any returned
check. Failure to pay will result in legal action and
your check will be forwarded to the County Attorney.
Page 1 of 3
ADMISSION AGREEMENT (CONT’D.)
TRANSPORTATION
1. The Center will provide transportation only to schools
at no extra cost.
2. Parent agrees to provide transportation for the child
if bus has left.
3. Field trips will be posted with advance notice at the
Center.
4. Parent authorizes emergency transportation for the
child if the child requires medical attention.
5. Parent understands that all fees incurred are the
Parent’s sole responsibility.
HOLIDAYS
The Center closes on the following days, and it is the
Parent’s responsibility to find accommodations for the
child if needed:
Memorial Day, Independence Day, Labor Day,
Thanksgiving Day and the day after, Thursday
and Friday prior to Easter Sunday, Christmas
Eve, Christmas Day, New Year’s Eve, New
Year’s Day
The Center reserves the right to change holidays from
those listed above. Notice will be given with at least 24
hours in advance. In case of inclement weather, the
Center will follow the guidance of the SISD and will
post notifications on FaceBook and on its website.
WITHDRAWAL/DROP
A written notice of your intent to withdraw your
child/youth from on-going programs is required two
weeks prior to effective date of withdrawal. This is
important. Notification helps us to effectively manage
our spaces and staffing and keeps you from accruing
needless fees.
WATER ACTIVITIES
No swimming will be offered at our Center. If we have
an extra-curricular water activity, notice will be given in
advance with a permission slip.
BIRTHDAYS
You may bring a cake and party favors for your child’s
birthday to the Center. Please make arrangements with
your child’s caregiver in advanced to reserve the day.
Celebrations will be held at the child’s classroom during
snack time.
MEALS
Little Footsteps Daycare is a member of the Special
Nutrition Program. This ensures your child receives a
nutritious meal, at every meal, every day. Our meal
schedule is as follows (Please note that your child will
ONLY be served those meals corresponding to the
LITTLE FOOTSTEPS DAYCARE & LEARNING CENTER
child’s schedule of attendance. If the child is late, meal
will not be served):
1. BREAKFAST
7:30-8:30 AM
2. LUNCH
10:30 – 11:30 AM
3. PM SNACK
2:45 – 3:45 PM
4. SUPPER
5:15 - 6:15 PM
DAILY SCHEDULE OF ACTIVITIES
A daily schedule of activities will be posted in each
classroom. These schedules provide the Parent will all
the programmed activities and lesson plans the class will
do, day by day.
PICK-UPS BY DESIGNATED OTHERS
The Center counts with a state-of-the-art security system
to ensure children are released to authorized persons.
You must notify the center if someone other than
yourself or your spouse will be picking up your child.
Center personnel will require the person’s state/valid
I.D. at the time of pick up.
ABUSE AND NEGLECT
The Center will report any suspected abuse or neglect to
the local authorities.
BEHAVIOR AND DISCIPLINE
The Center will not tolerate any discipline problems at
the facility. The Center will try to remedy any problems
according to our criteria and with the help of the Parent.
However, if the problem is persistent and is jeopardizing
the well-being and safety of other children and staff,
services will be terminated.
SUSPENSION
Our goal is to guide and direct children toward
acceptable behavior. Children engaging in persistent
displays of inappropriate behavior will be documented
on an incident/accident form and discussed with parent
to establish an intervention program. Parents will be
contacted and asked to remove their child if the child
becomes unruly, uncontrollable, or if his/her conduct is
such that it interferes with or harms other children (i.e.,
biting, scratching, fighting, throwing of any items,
pushing) and does not respond to adult authority. No
refund will be granted as a result of a suspension or
removal. The procedure for suspension of children from
our program is as follows:
1. Child will be separated from the group and the parent
will
be
notified
immediately
concerning
uncontrollable behavior or any incident resulting in
injury to another child, to the child, or to a staff
member.
Page 2 of 3
ADMISSION AGREEMENT (CONT’D.)
2. In the event of suspension, the numbers of days
and/or conditions for return will be determined on a
case-by-case basis which can include that the
parent(s) meets with the Director to discuss an agreed
upon intervention plan.
3. The decision to permanently remove a child from the
program will only take place after all alternatives
have been explored and tested.
4. Permanent removal will be determined by the
Director and teachers involved.
HYGIENE
Children are expected to be presentable every day to
attend the Center. Bathing, dental care, fingernail
trimming, and appropriate clothing are essential. Please
avoid being reminded of these very important matters.
BEDDING AND NAP TIME
Children will have a period of 2 hours to nap at the
Center. We will provide mats for your child. Parent is
responsible for bringing a small blanket with the child’s
name on it.
CIVIL RIGHTS CLAUSE
LITTLE FOOTSTEPS DAYCARE & LEARNING
CENTER does not discriminate against any child or
family on the basis of race, color, creed, national origin,
gender, or disability.
GENERAL PROVISIONS
Parent agrees to the following:
1. Comply with all rules, regulations, and policies as set
by Little Footsteps Daycare;
2. Provide all the necessary information required by the
Center in order to enroll the child;
3. Notify the Center of any change of address, telephone
number, and/or any other general information;
4. Make payments as stipulated at the time of
registration; and
5. Pick up child at the time stipulated in enrollment form
or before closing time, otherwise Parent agrees to pay
any additional charges as stipulated in the fees clause.
LITTLE
FOOTSTEPS
DAYCARE
AND
LEARNING CENTER agrees to:
1. Provide a safe, beneficial, and dynamic environment
for the child;
2. Ensure that the psychological, emotional, educational,
and behavioral well-being of the child is being
promoted; and
3. Provide excellent service, education, and supervision
to each child;
LITTLE FOOTSTEPS DAYCARE & LEARNING CENTER
4. Only use positive methods of guidance and
disciplining to help the child achieve self-control,
self-esteem, and independence.
AGREEMENT
_____ I have been given a copy of this agreement and I
fully understand each clause on each page.
_____ I agree to pay the amount due weekly or monthly
as specified in my enrollment form.
_____ I agree to pay the sum of $50.00 in registration
fees on a yearly basis.
_____ I understand I am solely responsible for any other
fees that may apply.
_____ I understand that my fee will not be changed,
refunded or modified due to holidays, shortterm illness, and/or occasional absences.
_____ I understand that if my payment is late, there
is a $10 per day fee.
_____ I understand I must provide the Center with any
legal document involving my child, such as
divorce papers, custody papers, court disputes,
etc.
_____ I understand that LITTLE FOOTSTEPS
DAYCARE & LEARNING CENTER reserves
the right to refuse service to any child that may
pose a threat to the safe, healthy, and beneficial
environment at the Center and all the staff and
children in it.
_____ By signing this document, I agree to all the above
clauses and understand that any policy may be
modified, changed, or added at any time with
proper notification to me. Failure to comply with
any of these policies can result in termination of
services.
Parent’s Signature
Center’s Representative
Date
Title
Date
Page 3 of 3
11720 Montana Ave. Building “B”
Phone: 915.849.9959 Fax: 915.849.9622
El Paso, TX 79936
www.mylittlefootsteps.com
Child’s School Information
Please provide the following information for each of your children who will need
transportation to and from school. Please make sure this information is always up to
date. We cannot add your child to our route without this information.
Child’s Name: _____________________________________________ DOB: _______________________________
School: _____________________________________________________ Grade: ___________________________
School Phone Number: ________________________________________
School Pick Up Time: ______________________
Pick Up Location: ________________________________________________________________________________
Mother’s Name: _______________________________________ Phone Number: ___________________________
Father’s Name: _______________________________________ Phone Number: ____________________________
If neither parent can be contacted, who do we contact in case of emergency?
Name: ______________________________________________ Phone Number: ___________________________
AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:
In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to: Name of Physician: ____________________________________________________________________ Address: ______________________________________ Ph.#: _______________________________
Name of Emergency Medical Care Facility: ____________________________________________________ Address: ______________________________________ Ph.#: _______________________________ I give consent for the facility to secure any and all necessary emergency medical care for my child. _________________________________________________ Signature -­‐ Parent or Legal Guardian
CACFP Infant Feeding Preference
Infant’s name: ___________________________ Infant’s Date of Birth: ____________
Little Footsteps Daycare & Learning Center will feed your infant breast milk provided by you
and/or we will provide iron fortified infant formula. The infant formula provided by this center is
Member’s Mark Iron Fortified Formula. The weekly fee for full time infant care in which we
provide formula is $150.00.
This center participates in the Child and Adult Care Food Program (CACFP) and receives USDA
reimbursement for serving nutritious meals to infants according to program requirements.
Participation in this program requires centers to follow specific meal patterns according to the age
of the infant or child.
Centers participating in the CACFP are required to offer infant formula to infants who are
enrolled for child care. Parents (or guardians) may decline the infant formula offered by the
center, and supply the infant formula themselves.
Parents (or guardians) complete the following tables as appropriate:
Please mark your preference
(choose all that apply)
Today’s Date
___________
Birth – 3 Months
Today’s Date
____________
4 -7 months
Today’s Date
___________
8 – 11 months
I will bring expressed breast milk
for my infant.
I want the center to provide the
infant formula for my infant.
I will bring the infant formula for
my infant. Please list the kind of
formula you will bring:
_________________
According to the CACFP requirements, in order to claim meals for reimbursement, the center must
provide infant cereal and other foods when your infant is developmentally ready to accept them.
Please mark your preference (choose all that apply)
Today’s Date
____________
4 -7 months
Today’s Date
___________
8 – 11 months
I want the center to provide the infant cereal and
other foods for my infant.
I will bring the infant cereal and/or other foods for my
infant.
Parent/Guardian’s Signature: ____________________________ Date: ______________
Little Footsteps Daycare
Discipline and Guidance Policy for ____________________________
Name of Operation
‹ Discipline must be:
(1) Individualized and consistent for each child;
(2) Appropriate to the child’s level of understanding; and
(3) Directed toward teaching the child acceptable behavior and self-control.
‹ A caregiver may only use positive methods of discipline and guidance that encourage
self-esteem, self-control, and self-direction, which include at least the following:
(1) Using praise and encouragement of good behavior instead of focusing only upon
unacceptable behavior;
(2) Reminding a child of behavior expectations daily by using clear, positive statements;
(3) Redirecting behavior using positive statements; and
(4) Using brief supervised separation or time out from the group, when appropriate for
the child’s age and development, which is limited to no more than one minute per year of the
child’s age.
‹ There must be no harsh, cruel, or unusual treatment of any child. The following types
of discipline and guidance are prohibited:
(1) Corporal punishment or threats of corporal punishment;
(2) Punishment associated with food, naps, or toilet training;
(3) Pinching, shaking, or biting a child;
(4) Hitting a child with a hand or instrument;
(5) Putting anything in or on a child’s mouth;
(6) Humiliating, ridiculing, rejecting, or yelling at a child;
(7) Subjecting a child to harsh, abusive, or profane language;
(8) Placing a child in a locked or dark room, bathroom, or closet with the door closed;
and
(9) Requiring a child to remain silent or inactive for inappropriately long periods of time
for the child’s age.
Texas Administrative Code, Title 40, Chapters 746 and 747, Subchapters L, Discipline and Guidance
My signature verifies I have read and received a copy of this discipline and guidance policy.
________________________________________________________
Signature
_________________
Date
Check one please:
x parent
TDPRS-CCL 06/02/03
… employee/caregiver
… household member of child-care home
TB Questionnaire
Name of Child____________________________________________________________Date of Birth ________________
Little Footsteps D.C. Date_______________________
Organization administering questionnaire______________________________________
Tuberculosis (TB) is a disease caused by TB germs and is usually transmitted by an adult person with active TB lung
disease. It is spread to another person by coughing or sneezing TB germs into the air. These germs may be breathed in by
the child.
Adults who have active TB disease usually have many of the following symptoms: cough for more that two weeks duration,
loss of appetite, weight loss of ten or more pounds over a short period of time, fever, chills and night sweats.
A person can have TB germs in his or her body but not have active TB disease (this is called latent TB infection or LTBI).
Tuberculosis is preventable and treatable. TB skin testing (often called the PPD or Mantoux test) is used to see if your
child has been infected with TB germs. No vaccine is recommended for use in the United States to prevent tuberculosis.
The skin test is not a vaccination against TB.
We need your help to find out if your child has been exposed to tuberculosis.
Place a mark in the appropriate box:
Yes
No
TB can cause fever of long duration, unexplained weight loss, a bad cough (lasting over two
weeks), or coughing up blood. As far as you know:
has your child been around anyone with any of these symptoms or problems? or
has your child had any of these symptoms or problems? or
has your child been around anyone sick with TB?
Was your child born in Mexico or any other country in Latin America, the Caribbean, Africa,
Eastern Europe or Asia?
Has your child traveled in the past year to Mexico or any other country in Latin America, the
Caribbean, Africa, Eastern Europe or Asia for longer than 3 weeks?
If so, specify which country/countries?______________________________________
To your knowledge, has your child spent time (longer than 3 weeks) with anyone who is/has
been an intravenous (IV) drug user, HIV-infected, in jail or prison or recently came to the
United States from another country?
Has your child been tested for TB?
Has your child ever had a positive TB skin test?
EF12-11494 TB Questionnaire for Children (Rev. 08/04)
Yes___ (if yes, specify date ____/____)
Yes___ (if yes, specify date ____/____)
No___
No___
Don't
Know
11720 Montana Avenue, Bldg. B, El Paso, Texas 79936 (915) 849.9959
4525-D Sun Valley, El Paso, Texas 79904 (915) 822.2264
[email protected]
www.mylittlefootsteps.com
fax: (915) 849.9622
Dear Parent/Guardian:
This letter is intended for parents or guardians of children enrolled in a child care center. [Name of Center] offers healthy meals to all
enrolled children as part of our participation in the U.S. Department of Agriculture’s (USDA) Child and Adult Care Food Program
(CACFP). The CACFP provides reimbursements for healthy meals and snacks served to children enrolled in child care. Please help us
comply with the requirements of the CACFP by completing the attached Meal Benefit Income Eligibility Form. In addition, by filling out
this form, we will be able to determine if your child(ren) qualifies for free or reduced price meals.
1. Do I need to fill out a Meal Benefit Form for each of my children in day care? You may complete and submit one CACFP Meal
Benefit Income Eligibility Form for all children enrolled in child care in your household only if the children in child care are enrolled in the
same center. We cannot approve a form that is not complete, so be sure to read the instructions carefully and fill out all required
information. Return the completed form to: [(Name of Center, address, phone number].
2. Who can get free meals without providing income information? Children in households getting Supplemental Nutrition Assistance Program
(SNAP) (formerly Food Stamps), Temporary Assistance for Needy Families (TANF), or Food Distribution Program on Indian
Reservations (FDPIR) can get free meals. Foster children (reference question #8 for more information on foster children) and children
enrolled in a Head Start Program (HSP), Early Head Start Program (EHSP), or Even Start Program (ESP) and have not entered
kindergarten) are also eligible for free meals. Households with children enrolled in a HSP, EHSP or ESP can provide a certification letter
from the program of the child’s enrollment and do not need to complete the CACFP Meal Benefit Income Eligibility Form.
3. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the
Income Chart, sent with this application. Children in households participating in WIC may be eligible for reduced price meals.
4. May I fill out a form if someone in my household is not a U.S. citizen? Yes. You or your children do not have to be U.S. citizens
to qualify for meal benefits offered at the child care center.
5. Who should I include as members of my household? You must include everyone in your household (such as grandparents, other
relatives, or friends who live with you) who shares income and expenses. You must include yourself and all children who live with you.
You also may include foster children who live with you.
6. How do I report income information and changes in employment status? The income you report must be the total gross income
listed by source for each household member received last month. If last month’s income does not accurately reflect your circumstances,
you may provide a projection of your monthly income. If no significant change has occurred, you may use last month’s income as a
basis to make this projection. If your household’s income is equal to or less than the amounts indicated for your household’s size on the
attached Income Chart, the center will receive a higher level of reimbursement. Once properly approved for free or reduced price
benefits, whether through income or by providing a current SNAP, TANF, FDPIR case number, you will remain eligible for those
benefits for 12 months. You should notify us, however, if you or someone in your household becomes unemployed and the loss of
income causes your household income to be within the eligibility standards.
7. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each
month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime,
include it, but not if you only get it sometimes.
July 2011
CACFP Meal Benefit Income Eligibility Form
Letter to Households (Child Care Centers)
8. What if I have foster children? Foster children that are under the legal responsibility of a foster care agency or court are eligible for
free meals. Any foster child in the household is eligible for free meals regardless of income. Households may include foster children on
the Meal Benefit Form, but are not required to include payments received for the foster child as income. Households wishing to apply for
such benefits for foster children can provide the Texas Department of Family and Protective Services Form 2085FC, Placement
Authorization Foster Care/Residential Care, to their child’s caregiver and do not need to complete the CACFP Meal Benefit Income
Eligibility Form.
9. We are in the military, do we include our housing and supplemental allowances as income? If your housing is part of the
Military Housing Privatization Initiative and you receive the Family Subsistence Supplemental Allowance, do not include these
allowances as income. Also, in regard to deployed service members, only that portion of a deployed service member’s income made
available by them or on their behalf to the household will be counted as income to the household. Combat Pay, including Deployment
Extension Incentive Pay (DEIP) is also excluded and will not be counted as income to the household. All other allowances must be
included in your gross income.
10. (Pricing program only) Will the information I give be verified? Maybe. We may ask you to send written proof to verify the
information you submitted on the form. What if I disagree with the decision about the information I complete on this form? You
can talk to Carol Kloper, Child Food Program Of Texas, at the phone number above. You may ask for a hearing by calling or writing to
Carol at Child Food Program Of Texas.
In the operation of child feeding programs, no person will be discriminated against because of race, color, national origin, sex, age or
disability.
If you have other questions or need help, call at the number above.
Sincerely,
Child Food Program Of Texas
July 2011
CACFP Meal Benefit Income Eligibility Form
Letter to Households (Child Care Centers)
11720 Montana Avenue, Bldg. B, El Paso, Texas 79936 (915) 849.9959
4525-D Sun Valley, El Paso, Texas 79904 (915) 822.2264
[email protected]
www.mylittlefootsteps.com
fax: (915) 849.9622
Estimado Padre/Tutor:
Esta carta está dirigida a todos los padres o tutores de niños que están inscritos en centros de cuidado infantil. [Nombre del
Centro] ofrece comidas saludables para todos los niños inscritos como parte de nuestra participación en el Programa de
Atención Alimenticia para Niños y Adultos (CACFP, por sus siglas en inglés) del Departamento de Agricultura de Estados
Unidos (USDA, por sus siglas en inglés).
El CACFP ofrece reembolsos por comidas y meriendas saludables que se les sirven a los niños inscritos en centros de cuidado
de niños. Por favor, ayúdenos a cumplir con los requisitos del CACFP llenando el Formulario de Calificación por Ingresos para
el Beneficio de Comidas que está adjunto a esta carta. Además, al llenar este formulario, podremos determinar si su hijo(s)
califica para recibir comidas gratis o a un precio reducido.
1. ¿Debo llenar un Formulario de Calificación para el Beneficio de Comidas por cada hijo que esté en un centro de
cuidado diario? Podría ser que tenga que completar y presentar un Formulario de Calificación por Ingresos para el Beneficio
de Comidas del CACFP para todos los niños de su hogar que están inscritos para recibir cuidado diario, pero sólo si están
inscritos en el mismo centro. No podemos aprobar un formulario que no esté completo, por eso, debe asegurarse de leer las
instrucciones con cuidado y llenar toda la información que se solicita. Devuelva el formulario ya llenado a: [nombre del
centro, dirección, número de teléfono].
2. ¿Quién puede recibir comidas gratis sin tener que entregar información sobre ingresos? Pueden recibir comidas gratis los
niños en hogares inscritos en el Programa de Asistencia de Nutrición Suplementaria (SNAP) (anteriormente “Estampillas para comida”),
Asistencia Temporal para Familias Necesitadas (TANF), o el Programa de Distribución de Alimentos en Reservaciones Indígenas (FDPIR). Los
niños en familias de crianza (consulte la pregunta Nº 8 si desea más información sobre niños de crianza) y los niños inscritos
en el Programa “Head Start” (HSP), el Programa “Early Head Start” (EHSP), o el Programa Even Start ESP) y que aún no han
comenzado el jardín infantil, también califican para recibir comidas gratis. Los hogares que tienen niños inscritos en un HSP,
EHSP, o ESP, pueden entregar una carta de certificación del programa de que el niño está inscrito, y así no necesitan llenar un
Formulario de Calificación por Ingresos para el Beneficio de Comidas del CACFP.
3. ¿Quién puede recibir comidas a precios reducidos? Los niños pueden recibir comidas a precios reducidos si los ingresos de su hogar
están dentro de los límites de precios reducidos de la Tabla de Ingresos que se envió junto con esta solicitud. Los niños en hogares que participan
en WIC podrían calificar para recibir comidas a precio reducido.
4. ¿Puedo llenar el formulario si en mi hogar hay una persona que no es ciudadano estadounidense? Sí. Ni usted ni sus
hijos tienen que ser ciudadanos estadounidenses para calificar para el beneficio de comidas del centro.
5. ¿A quiénes debería incluir como miembros de mi hogar? Debe incluir a todos los miembros de su hogar (es decir, los
abuelos, otros parientes, o amigos que viven con usted) que comparten los ingresos y los gastos. Debe incluirse usted mismo y
a todos los niños que viven con usted. También puede incluir a los niños de crianza que viven con usted.
6. ¿Cómo entrego la información sobre mis ingresos y notifico los cambios en mi situación laboral? Su informe de
ingresos debe presentar los ingresos totales brutos recibidos el último mes por cada miembro del hogar indicando la fuente. Si
su informe de ingresos del último mes no refleja con exactitud su situación, puede presentar una proyección de sus ingresos
mensuales. Si no ha tenido cambios importantes, puede usar los ingresos del mes pasado como base para preparar esa
proyección. Si los ingresos de su hogar son iguales o inferiores a los montos indicados para el tamaño de su hogar en la Tabla
de Ingresos adjunta, el centro recibirá un mayor nivel de reembolsos. Una vez que tenga la aprobación para recibir beneficios
gratis o a precios reducidos, ya sea mediante ingresos o presentando un número de caso vigente del SNAP, TANF, o FDPIR,
usted seguirá calificando para recibir esos beneficios por 12 meses. Sin embargo, deberá notificarnos si usted o alguien de su
hogar queda desempleado y la pérdida de ingresos hace que los ingresos de su hogar queden dentro de los parámetros para
calificar.
7. ¿Qué puedo hacer si mis ingresos no siempre son iguales? Indique el monto que percibe normalmente. Por ejemplo, si
sus ingresos mensuales generalmente son de $1000, pero en el último mes no trabajó tanto y sólo recibió $900, indique que
recibe $1000 mensuales. Si generalmente trabaja horas extras, debe incluir eso también, pero no lo incluya si es solamente a
veces.
Julio 2011
Formulario de Calificación por Ingresos para el Beneficio de Comidas del CACFP
Carta a los Hogares (Centros de Cuidado de Niños)
8. ¿Qué hago si tengo niños de crianza? Los niños de crianza que están bajo la responsabilidad legal de una agencia o un
tribunal de crianza califican para recibir comidas gratis. Cualquier niño de crianza del hogar califica para recibir comidas gratis
independientemente de los ingresos del hogar. Los hogares pueden incluir a niños de crianza en el Formulario de Beneficios de
Comidas, pero no están obligados a incluir los pagos recibidos para el niño de crianza como ingresos. Los hogares que deseen
solicitar esos beneficios para los niños de crianza pueden entregar al cuidador del niño el Formulario 2085FC Autorización de
Colocación en Crianza / Cuidado Residencial del Departamento de Servicios para la Familia y de Protección de Texas, y así no
tendrán que llenar el Formulario de Calificación por Ingresos para el Beneficio de Comidas del CACFP.
9. Pertenecemos al ejército, ¿debemos incluir nuestras pensiones de vivienda y suplementaria como ingresos? Si su
vivienda forma parte de la Iniciativa de Privatización de Viviendas del Ejército, y además recibe Un Beneficio Suplementario de
Subsistencia Familiar, no incluya esas pensiones como ingresos. Además, con relación a miembros del ejército en zonas de
combate, sólo se contará como ingresos del hogar la parte de los ingresos del miembro del ejército que hayan sido designados
por él o a nombre suyo para que vayan al hogar. Los sueldos por combate, incluyendo el Pago de Incentivos de Extensión de
Servicio (DEIP) también quedan excluidos y no se contarán como ingresos del hogar. Todas las demás pensiones se deben
incluir en sus ingresos brutos.
10. (Únicamente para el programa de precios) ¿Se verificará la información que yo presente? Quizás. Quizás le pidamos
que envíe prueba escrita para verificar la información que presentó en el formulario. ¿Qué pasa si no estoy de acuerdo con
la decisión que se tome sobre la información que yo coloque en este formulario? Puede comunicarse con [ingrese el
nombre de la persona que está a cargo de manejar las quejas/desacuerdos], ya sea en persona o mediante el siguiente
número de teléfono: [ingrese el número de teléfono del empleado ya mencionado]. Puede solicitar una audiencia llamando o
escribiendo a: [nombre, dirección, número de teléfono].
En el manejo de los programas de alimentación infantil, no se discriminará a personas según su raza, color de la piel,
nacionalidad de origen, género, edad, o discapacidad.
Si tiene alguna otra pregunta, o necesita ayuda, llame al [número de teléfono].
Atentamente,
[firma]
Julio 2011
Formulario de Calificación por Ingresos para el Beneficio de Comidas del CACFP
Carta a los Hogares (Centros de Cuidado de Niños)
CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)
Part 1. All Household Members
Name of Enrolled Child(ren):
CHECK IF A FOSTER CHILD (THE
LEGAL RESPONSIBILITY OF A
WELFARE AGENCY OR COURT)
* IF ALL CHILDREN LISTED BELOW
ARE FOSTER CHILDREN, SKIP TO
PART 5 TO SIGN THIS FORM.
Names of all household members
(First, Middle Initial, Last)
CHECK
IF NO INCOME
Part 2. Benefits: If any member of your household receives SNAP, TANF, or FDPIR, provide the name and case number for the person
who receives benefits. If no one receives these benefits, skip to part 3.
NAME:_________________________________________________ CASE NUMBER: _________________________________
Part 3. (Applies only to parents/guardians with children enrolled in a day care home) If any member of your household receives
benefits listed on the enclosed List of Eligible Federal/State Funded Programs (H1660), provide the name of the program and case
number: NAME:
___________________________________ CASE NUMBER:
____________
Check here if no case number
Part 4. Total Household Gross Income—You must tell us how much and how often
B. Gross income and how often it was received
Note: Self-employed report income after expenses in box 1
A. Name
3. Pensions, retirement,
1. Earnings from work 2. Welfare, child support,
(List only household members with before deductions
alimony
Social Security, SSI, VA
benefits
income)
(Example)
$200/weekly_____
$150/twice a month_
$100/monthly_____
Jane Smith
$
/
$
/
$
/
4. All Other Income
$200/bi-monthly
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
$
/
Part 5. Signature and Last Four Digits of Social Security Number (Adult must sign)
An adult household member must sign this form. If Part 4 is completed, the adult signing the form must also list the last four digits
of his or her Social Security Number or mark the “I do not have a Social Security Number” box. (See Privacy Act Statement on the
next page.)
I certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get
Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I
purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.
Sign here: _________________________________________
Print name: ________________________________________
Date: ____________________________
Address: ___________________________________________
Phone Number: _______________________
City:_______________________________________________
State: ________________
Last four digits of Social Security Number: _* _* _* - _* _* - __ __ __ __
July 2014
Zip Code: ________________
I do not have a Social Security Number
CACFP Meal Benefit Income Eligibility
Child Care Form
Page 1
CACFP MEAL BENEFIT INCOME ELIGIBILITY FORM (Child Care)
Part 6. Participant’s ethnic and racial identities (optional)
Mark one ethnic identity:
Mark one or more racial identities:
Hispanic or Latino
Asian
American Indian or Alaska Native
Not Hispanic or Latino
White
Native Hawaiian or Other Pacific Islander
Black or African American
Part 7. Sharing Information With Other Programs: OPTIONAL
The above information may be disclosed for the purpose of enrolling children in the Children’s Health Insurance Program (CHIP).
Parents/guardians are not required to consent to such disclosure and electing not to allow disclosure will not adversely affect a child’s
eligibility.
I do elect to allow my household information to be disclosed.
I do not elect to allow my household information to be disclosed.
Don’t fill out this part. This is for official use only.
Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24, Monthly x 12
Total Income: ____________ Per: Week, Every 2 Weeks, Twice A Month, Month, Year
Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___
Household size: _________
Tier I_____
Tier II____
Reason: _____________________________________________________________________________________________________
Determining Official’s Signature: _______________________________________________________________ Date: ______________
Confirming Official’s Signature: ________________________________________________________________ Date: ______________
Follow-up Official’s Signature: _________________________________________________________________ Date:______________
Privacy Act Statement:
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information,
but if you do not, we cannot approve the participant for free or reduced price meals. You must include the last four digits of the Social
Security Number of the adult household member who signs the application. The Social Security Number is not required when you apply
on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families
(TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number for the participant 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 the participant is eligible for free or reduced price meals, and for administration and enforcement of
the Program.
Non-discrimination Statement:
The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the
bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital
status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance
program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all
prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found
online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You
may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail
at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by
fax (202) 690-7442 or email at [email protected].
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 8778339; or (800) 845-6136 (Spanish).
USDA is an equal opportunity provider and employer.
July 2014
CACFP Meal Benefit Income Eligibility
Child Care Form
Page 2