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Hotel Casino Internacional Cucuta Departamento De Norte De
Happy
Hippopotamus
Daycare Academy
East
QJ Admission
Book'et~
*Please complete all forms in this booklet and return to the Director*
Texas Dept of Family
and Protective Services
Form 2935
Oct 2008 I Pg 1 of 3
ADMISSION INFORMATION
Operation Name
Director's Name
Happy Hippopotamus Daycare Academy East
Yvette Holt
Child's Full Name
Child's Date of Birth
I
Child's Home Telephone
No.
Child's Home Address
I
Dale of Admission
Parent's or Guardian's
Date of Withdrawal
Name
Address (if different from child's address)
List telephone numbers below where parents/quardian may be reached while child will be in care:
Mother's Telephone No.
Father's Telephone No.
Guardian's Telephone
I
I
Give the name, address and phone number of person to call in case of an emergency
Cell Phone No
No.
I
if parents I guardian cannot be reached:
I
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 parenUguardian after verification of 10.
I
CHECK
1.0
2.0
ALL THAT APPLY:
FIELD
Parent's
3.0
4.
0
I hereby
TRANSPORTATION:
o
TRIPS:
o
give
for emergency
I hereby
0
give
I hereby
0
give
- consent for my child to be transported
operation's
employees:
do not give
o
care
o
o
on field trips
- my consent
do not give
to and from home
and supervised
o
by the
to and from school
for my child to participate
in Field Trips:
for my child to participate
in Water
Comments:
WATER
ACTIVITIES:
o sprinkler
RECEIPT OF WRITTEN OPERATIONAL
I acknowledge
5. I UNDERSTAND
o
0
I
receipt
None
OBreakfast
6. MY CHILD IS NORMALLY
DAM
o Wednesdays
o Fridays
o Thursdays
o Saturdays
D Sundays
o
swimming
pools
Activities:
o water
table play
POLICIES:
operational
policies
including
those for discipline
and guidance.
MEALS WILL BE SERVED TO MY CHILD WHILE IN CARE:
o
Snack
IN CARE ON THE FOLLOWING
o Mondays
o Tuesdays
AUTHORIZATION
of the facility's
THAT THE FOLLOWING
o do not give - my consent
o splashing/wading pools
play
from:
to:
from:
from:
to:
Lunch
o
PM Snack
o
Supper
OEvening
Snack
DAYS AND TIMES:
to:
from:
to:
from:
to:
from:
to:
from:
to:
FOR EMERGENCY MEDICAL ATTENTION;
In the event I cannot
Name of Physician:
be reached
Name of Emergency
Medical
to make arrangements
Care Facility:
for emergency
medical
care, I authorize
the person
in charge
to take my child to:
Address:
I"h.#:
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
SCHOOL
D
Form 2935
Oct 2008 / Pg 2 of 3
ADMISSION INFORMATION
AGE CHILDREN:
My child attends
the f~lI~wing
sch~ol:
School
Name of School and Address
Ph.#
CHECK ALL THAT APPLY:
o
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:
o
ride a bus, and/or
D walk
to and from school,
o be released
to the care of his/her
sibling(s) under 18 years old.
Name of sibling(s):
IMMUNIZATION
RECORD:
o I have provided the childcare operation with a copy of my child's most current immunization
record.
ADMISSION REQUIREMENT:
If your child does not attend pre-kindergarten
or school away from the child-care operation,
following must be presented when your child is admitted to the child-care operation or within one week of admission.
one of the
Please check only one option:
1.
0
HEALTH-CARE PROFESSIONAL'S STATEMENT:
able to take part in the day care program.
2.
D
D
A signed and dated copy of a health care professional's
I have examined
Health Care Professional's
3.
the above named child within the past year and find that he / she is
Date
Signature
statement
is attached.
Medical diagnosis and treatment conflict with the tenets and practices of a recognized
member of; I have attached a signed and dated affidavit stating this.
religious organization,
which I adhere to or am a
D
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
slqned statement and will submit it to the child-care operation.
Name and address of health care professional:
4.
Signature - Parent or Legal Guardian
Date
L 20/
R 201
D
PASS
0
FAIL
o
PASS
0
FAIL
DATE
HEARING
1000 Hz
2000 Hz
4000 Hz
R
L
SIGNATURE
DATE
Signature
- Parent
or Legal
Guardian
Date
TQxas DQPt of Family
____________________________
II
Form 2935
ADMISSION INFORMATION
and Protective Services
Oct 2008 I Pg 3 of 3
2H~E~A~L~T~H~R~E~Q~U~IR~EM~EN~T~S~
~~
Date of Birth:
[email protected] of Child
/I
1/
~----------------------------------------------------~~
~~~H~e~pa~t~it~is~B~
~
~
~L...:.;:R.::::o.::ta:..:v~ir""u:.=s~ ~
~ Diphtheria,
Tetanus,
~L~P::.ert~u~ss~i~S
--'-
~
~
~ Haemophilus
~~I!!.n!!.fl:.=u:.=e.:..:n""za""e~tyu:p:.=e:....!b""___
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Poliovirus
~L...!.!ln!!.f:.=lu:.=e.:..:n""z"'-a
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~ Varicella
~L__
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'---
...l.___
~LH~e~p~a~tit~is~A~
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'__
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(chickenpox)
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Positive
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disease
Parent's
(chickenpox)
IIn
----'---
Date:
Negative
__
vaccine is not required if your child has had chickenpox disease.
statement: My child had varicella
~
...L..
----l~
~S~ig~n~a~tu~re~
II Varicella
~
~
_'_
~
Signature or stamp of a physician or public health
personnel verifying immunization information above.
o
~
'--
L-
II
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~
'-
II
~
----''-'-
-L-
TB TEST (if required)
~
~
~ Measles, Mumps,
~~R.!:!.U.!:!b::.el!.!!la!!-
nULC.Meningococcal
==_==~
~
'-
'-
Inactivated
~
~
---'~
II
~
on or about (date)
D~at~e~
If your child has had chickenpox,
-----------
signature
please complete the
and does not need varicella
vaccine.
Date
I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official
notarized affidavit form develo ed and issued b the De artment of State Health Services. I understand this affidavit is valid for 2 ears.
For additional information regarding immunizations
contact the Department
www.dshs.state.tx.us/immunize/public.
Signature - Parent or Legal Guardian
of State Health Services at
shtm
Date
~
Happy Babypotamus Care Information Sheet
Name:
Date of Birth: --------
Type ofForrnula:
Heated?:
_
Type of Juice(s):
_
Type of Solids: Cereal:
Meats:
Vegetables:
Fruits:
_
---------
Allergies:
_
Allergic Symptoms:
_
Does your baby use a pacifier?
_
Other Helpful Information:
_
Thank you for all your help!
Parent Signature:
~
Please keep us updated as things change with your baby.
Date:
_
Child's Name;
Preferred Name;
Age:
-----------------------------------.-:Date of Birth:
_
In order for us to provide quality care for your child, I need to understand a bit about his/her
developmental history. Feel free to write in as much information as you like. Use the reverse side of
this form if necessary. We realize this is a lot of information but also very important for your childs
teacher. We thank you in advance.
ACTIVITIES:
Please list your child's favorite toys and activities.
What do you consider your child's activity level to be like:
[ ] Normal
[] Tends to get a bit hyper
[ I Prefers reading and quiet activities to outdoor play
[ ] Prefers to be outside
HEALTH:
Does your child suffer from food allergies or insect bites? [] YES [] NO
If yes, Please explain what needs to be done in these instances:
Is there any thing I should know about your child's physical or mental health?
If yes, please elaborate:
Has your child been hospitalized? Explain:
Has your child had any injuries with fractures or loss of consciousness?
[] YES
[] NO
_
Explain:
Do any members of your family have a history of: Asthma __
Diabetes
Does your child have problems with: (circle all that apply)
Constipation
Convulsions
Diarrhea
Fainting Spells
Skin Rash
Ring Worm
Lice
Stomach Upsets
Worms
Ear Infections
Soiling
Has your child had any ofthese diseases: (circle all that apply)
Asthma
Bronchitis
Diabetes
Chicken Pox
Measles
Mumps
Hepatitis
Impetigo
Scarlet Fever
Tuberculosis
Polio
Whopping Cough
Epilepsy
_
Frequent Colds
Sore Throats
German Measles
Heart Disease
SLEEPING HABITS:
Does your child nap? [] YES [] NO
Do you keep your child on a regular nap-time schedule? [] YES [] NO
At what time does he/she generally like to sleep?
_
Does your child have a favorite toy, blanket etc. he/she like to sleep with? [] YES
If yes. please elaborate:
What is your child's temperament when he/she wakes up?
[] NO
_
_
TOILET HABITS:
Is your child toilet trained? [] YES [] NO
What word does your family use for urination?
For bowel movements?
--------Does your child have accidents? [] YES [] NO
If yes, please explain how you handle this:
Does your child wear diapers during nap times?
[] YES
_
_
[] NO
SOCIAL DEVELOPMENT:
Is your child used to playing with other children? [] YES [] NO
Does your child have trouble separating from you when being dropped off? [] YES [] NO
If yes, what do you do to assist your child?
Does your child make shy or have trouble adjusting to new places and faces? [] YES [] NO
If yes, how do you assist your child?
Does your child have a tendency to run away? [] YES [] NO
How does your child express anger or frustration?
~,,__._--~-Does your child have a tendency to throw temper tantrums? [] YES [] NO
If yes, how do you handle this?
When your child is upset, what do you do to comfort him/her:
Does your child have any special fears?
What method of discipline do you use with your child?
_
_
_
_
_
----:-
Is there anything you are concerned about where your child's social development is concerned?
[ ] YES [ ] NO
If yes, please elaborate:
_
_
Are there any development concerns diagnosed or suspected with your child (i.e.: advances, slow)?
[ ] YES [] NO
If yes, what are the recommendations for working with your child?
_
LANGUAGE DEVELOPMENT:
Is your child using words? [] YES [] NO
Does your child speak in sentences? [] YES [] NO
Is a second language spoken in your home? [] YES [] NO What language?
Does your child have difficulty with his/her speech? [] YES [] NO
If yes, please elaborate:
_
_
FOODS:
What foods does your child like?
_
What foods does your child dislike?
What do you do when your child refuses to eat?
_
_
What drinks does your child prefer?
Does your child drink a lot of liquids? [ ] YES [] NO
Do you water down fruit juices?
[] YES [] NO
_
ADJUSTMENT:
Do you expect any adjustment problems when your child begins care? Explain:
Previous child care attended:
-------------------------Any problems at previous child care:
-------------------------
FAMILY LIFE:
Can you please tell me who else live at home with you and your child?
Name:
Nick Name:
Relationship:
_
Name:
Nick Name:
Relationship:
_
Name:
Nick Name:
Relationship:
_
Please note here any special family concerns I should be aware of such as custody arrangements or
other family situations.
_
OTHER INFORMATION:
Please tell me anything else you would like me to know about your child (his/her general personality,
tendency towards affection, etc.).
Tuition AgreementIN otification
Tuition Scale 2011
Happy Hippo Tuition Scale
Effective Sept 1. 2011
8abypotamus
1----------------
(6 Weeks to 18 months Old)
Full Day
15 Days
135
.
Toddlerpotamus
1
I----------------
(18 months to 2 years Old)
F_u_II_D_a_y
-t-
5 Days
110.
Kiddopotamus
(3-5 Years Old)
15 Days
Juniorpotamus
(5 Years Old Kindergarten and up)
Full Day (Summer)
After School
105
60
5 Days
Extra Charges
I
Off School Days
Drop-In-Fee
See director
I
I
I
$25 per day per child over 18 mos; $30 per day if under 18mos.
I
Depending
on available room
Registration Fee
$60.00 non-refundable
Transportation
Standard fee $.65 per mile, per student.
Fee
enrollment fee, per child, per year
Multi-Child Discount
$10.00 discount (off tuition only) per family, does not apply to drop in service.
Late Fees
$1.00 per minute per child after 6:00 p.m. No exceptions.
Field Trips
Most field trips have transportation
and admission costs associated with them,
which are assessed individually.
Return CheckJACH Fee
$30.00 per return. Cash restitution must be made for the missed payment
before services can resume.
My signature verifies I have read and received a copy of this Tuition Agreement and
Discipline/Guidance Policy within my parent handbook.
Signature
Parent
Date
Check one please:
Employee/Caregiver
Guardian! other
Childs Name:
-------------------------------
Permission:
1. I,
hereby give my consent for Happy
Hippopotamus Daycare Academy to the following:
__
apply __
do not apply sunscreen to exposed skin areas before going
outside as directed by the sunscreen manufacturer.
__
take __
do not take pictures/ videos for use only in the facility.
Parent Signature:
_
EMERGENCY CONTACTS AND INFORMATION
Child's Name:
_
Parent's Full Name:
------------------------ Home Phone: --------------Address:
-------------------------------City: ----------------- State: -------- Zip Code: ------------Mother's Work No.:
ext.
Pager or Cell Phone:
_
Name of Employer
_
Father's Work No:
ext,
Pager or Cell Phone:
_
Name of Employer
_
Special Instructions for contacting parents at work:
_
Primary Emergency Contact (other than parents or guardian). Minimum of two people.
Name: ---------------------Home Phone:
Work Phone: ------------Relationship to Child:
_
Address:
---------------------------------Secondary Emergency Contact (other than parents or guardian).
Name:
--------------------Home Phone:
Work Phone: ------------Relationship to Child:
_
Address:
----------------------------------
EMERGENCY INFORMATION
1. Child's Physician: ---------------
Phone: --------------
3. Preferred Hospital:
Phone:
_
5. Regular Medications:
_
7. Medicine allergic to:
------------------------8. Food Allergies:
_
9. Any other Allergies:
_
10. Immunization Record: Date of Last Immunization: -----------------11. Any special health conditions:
12. Child has had:
[
[
[
[
[
[
]
]
]
]
]
]
Measles
German Measles
Chicken Pox
Mumps
Whopping Cough
Other
_
Child suffers from:
[ ] Headaches
[ ] Earaches
[ ] Sore Throat
[ ] Stomach Aches
[ ] Flu / Colds
[ ] Other
_
I
KEEFING
OUR
YOUNG
ONES
SAFE
Child Protection Policy
of
Happv Hloooootamus
Daycare Academy
1 1ex:> N.£~.f.mat'\
1-000~Y'icw-rx,
. -'151.01
l~) 2.!N" ""
908 ~-69L-806
CHILD PROTECTION POLICY
A Child Care Provider is obligated by law to
report any suspected cases of child abuse.
This obligation is taken very seriously.
The Happy Hippopotamus
Daycare Academy recognizes the need to provide a sate and
caring environment for our young people. We believe children have the right ID be free from the
fear or reality of abuse (either physical or emotional). At Happy Hippo, we are fully committed
to protecting the security, privacy. and dignity ofthc children who have been allowed to take part
in our child care program, The Happy Hippopotamus Daycarc Academy has therefore adopted
the procedures set out in this document to keep the children in its care free from abuse of any
kind.
.
STATE1\ffiNT
OF I\-OTIFICATION
Before a child will be allowed into care, the parent{s) MUST sign a statement confirming
they are aware that the Caregiver's duty, under the law, is to report suspected child abuse or
neglect. The signed statement will be kept in the child's file.
I\OTIFICATION
OF INJURY DURING OUT-OF-CARE HOURS
Parents MUST inform the Caregiver of any visible injuries or marks on a child
(accidental or non-accidental)
as soon as the child arrives. It is in the best interest of the parent
to tell the Caregiver how the injury occurred and what action has been taken to care for the
injury, if any.
SUSPICIONS
OF PHYSICAL INJURY OR NEGLECT
Under no circumstances will Happy Hippopotamus Daycare Academy carry out its own
investigation into the allegation or suspicion ofabuse, If child abuse is disclosed or discovered,
or it appears that a ch ild has been harmed in some way by his or her parents or other PC'TSOn5, the
Caregiver win immediately seek advice from her Child Care Worker or from the Licensing
Office/Licensing
Agency prior to speaking with the parents. Suspicions Wl LL not be discussed
with anyone other than those mentioned above. The family's identity will not be revealed at this
point- However, a written Suspicion of Child Abuse Report will be made and kept in a secure
place,
2
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RESPONDING TO ALLEGATIONS OF ABUSE
It: after this consultation
with the Licensing Office it is agreed that the matter should be
rderred to Social Services or Child Protective Services, the parents wiii he informed prior to the
report being su bmitted, unless it is deemed that by informing the parents the child may come to
further harm In serious cases. the Police many be involved without parental consent or
knowledge.
When warranted, the Happy Hippopotamus Daycarc Academy will seek medical
help for the child jf needed, in forming the doctor of any suspicions.
Ifthere is a concern about signs ofneglect ofthc child or noticeable changes to the
child's behaviour or temperament,
the Caregiver will discuss these concerns with the parents. If
the concerns arc not addressed in a forthright or satisfactory manner, the parents will be informed
that 'he matter will be handed over to Social Services or Child Protective Services.
I
ALtEGATIONS
OF SEXUAL ABUSE
I
In cases where the Caregiver suspects that the child may have been sexually abused, the
Caregiver will contact Social Services Of Child Protective Services WfTHOUT informing the
parents.
The Caregiver will then seek and follow the advice given by the Licensing Office if for
any reason they are unsure whether or not to contact Social Services, Child Protection Services
or the Police. The Caregiver will confirm its advice in writing for future reference.
INVESTIGATING A REPORT
If a report to Social Services or Child Protective Services triggers an investigation, the
aforementioned
Suspicion of Child Abuse Report may be handed over to the investigating party.
The Suspicion of Child Abuse Report will contain the following information:
@.. The child's name,
address, date of birth, parents' names, doctor's name;
abuse, what the concerns arc, and how or why they have
.~ Particulars of the suspected
@'
@.
@.
@.
~.
[email protected],
[email protected]
@
@.
arisen;
Si!:,'TIS or evidence of the suspected abuse;
The type of injury and the location of the injury on the child;
Any medical treatment that was sought for the injury;
Any recent noticeable changes in the child's behaviour or temperament;
Suspected perpetrator information (if known or if divulged by the child);
Any previous concerns about the child or other children in the family;
Any family problems that have occurred;
Medical history ofthe child, jf applicable;
Any other people, agencies, or organizations that are invo lvcd with the child or the
family (if known);
(~. Results of the consultation
with the parcnts.fheir reaction to the concerns, etc.;
@' A Est of any agencies that have become involved as a result of direct contact from the
Caregiver about the suspicion of abuse;
[email protected] Name of the person making the report;
@. Signature of the parents during consultation
3
en7:nl
II
17 dao
T1~ following an initial inquiry, the concerns are not substantiated, the parents will be
informed,
and the matter will be terminated.
The parents may, however, be offered on-going
help by Social Ser.vices.
If the inquiry reveals that the child is/bas been harmed in some way. various courses of
action may be taken depending on the circumstances of the case. It will be up to Social Services,
Child Protection Services or the police what course of ad ion 'win be taken after this point.
Happy Hippopotamus
Daycare Academy WfLL no longer be involved in the matter unless
requested to be so by the investigating body.
TRAINING
OF WORKERS,
VOLUNTEERS
& SUBSTITUTE STAFF
Happy Hippopotamus Daycare Academy recognizes that it is the responsibility of each
one of its staff paid and unpaid, to prevent the neglect, physical, sexual or emotional abuse of
children and to re-port any abuse discovered or suspected.
The Happy Hippopotamus
Daycare Academy will therefore ensure that all workers,
volunteers or substitute providers will be trained in accordance with the principles set out in this
Child Protection P-olicy. All workers will be aware of the appropriate reporting procedure.
Workers will inform their direct supervisor or other designated person appointed to handle
suspicions of child abuse.
HELPING
CHILDREN
TO UNDERSTAND
ABUSE
The Happy Hippopotamus
Day-care Academy, may arrange tor training for its young
charges to learn more about good and bad touching, abuse, and when to talk to someone if they
feel they have been abused in any way, Such training will involve the use of age appropriate
books and activities as recommended by the local librarian and Social Services and Health
Services departments. When applicable, Happy Hippopotamus Daycarc Academy will invite a
member of Social Services, Health Department or Child Protection Services in to talk with the
children. We will also seek out any programs that can help us in the endeavor.
Area Telephone Numbers
Licensing Office: 903-233-5237
SociaUChild Protection Services: 1-800-252-5400
Police: 903-237-1199
Child Abuse Hotline: 1-800-252-5400
4
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Happy Hippopotamus Daycare Academy
CHILD PROTECTION POLICY
PARENTAL
CONSENT & ACKNOWLEDGEl\IENT
Please read the Child.Protection
FORM
Policy before signing this form.
By signing this Parental Consent and Acknowledgement Form, I acknowledge and agree that:
1. I have read and understood the Child Protection Policy of Happy Hippopotamus Daycare
Academy;
2. To the extent that I have had questions concerning any ofthose policies or statements, I
have contacted
t (Director) and those questions have been answered to my
satisfaction;
YtIc.+IL •••••
3. I am the Child's parent or legal guardian with full right to consent to this
acknow ledgement;
4. I consent to my Child's enrollment at Happy Hippopotamus Daycare Academy, and for
the safety and well-being of my child, I also consent to the collection of personal
information about my Child in the manner described in the Child Protection Policy
should the Caregiver become suspicious of any type of abuse of my child; and
5. My Child and I/We will be bound by the terms outlined in this Child Protection Policy.
Mother/Guardian's Name:
Signature:
,.
_
Date:
_
_
Date:
_
Date:
_
Father/Guardian's Name:
Sign~tqrc;
Caregiver's ~ ame: --Signature;
-""'0-----------
_
5
909 ~-69L-£06
Happy Hippopotamus
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)
0
0
0
0
0
0
0
CHECK
IF NO INCOME
0
0
0
0
0
0
0
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 0
Part 4. Total Household
Gross Income-You
must tell us how much and how often
B. Gross income and how often it was received
A. Name
(List only household memberswith
income)
(Example)
Jane Smith
1. Earnings from work 2. Welfare, child support,
before deductions
alimony
3. Pensions,retirement,
Social Security,SSI, VA
benefits
4. All Other Income
$200/weekly
$150/twice a month
$100/monthly
$200/bi-monthly
$-_/_-
$-_/_-
$-_/_-
$-_/_-
$-_/_-
$__
1_-
$-_/_-
$-_/_-
$-_/_-
$__
1_-
$__
1_-
$__
1_-
1_-
$__
1_-
$__
1_-
$-_/_-
$__
1_-
$__
$-_/_-
$__
1_-
$-_/_-
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.)
/ certify that all information on this form is true and that all income is reported. 1
understand that the center or day care home
will get Federal funds based on the information / give. / 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.
Print name:
Sign here:
Date:
Address:
Phone Number:
City:
State:
Last four digits of Sociql Security Number: .: ~ ~ - ~ ~ - ____
July2011
Zip Code:
o I do not have a Social Security Number
CACFP
MealBenefitIncomeEligibility
Child Care Form
Page1
Items Needed For Child Care
Baby and InfantBaby Wipes
Diapers
Complete Change of Clothes
Baby Food
Baby Cereal
Baby Juice
Bottles for each feeding
Water for formula
Pacifier (if they use one)
Nap mat
( if child is walking)
Blanket
Children 18mo. And OlderBaby Wipes
Diapers/ Pull Ups
Complete Change of Clothes
Nap mat
Blanket
Special sleep ( stuffed animal)
(ANY SPECIAL DJET NEEDS NOTE FROM THE DR.)
This includes lactose free,

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