Please answer both questions. This information is voluntary.
5
ETHNIC/RACIAL
CATEGORIES—
A. Ethnic data of child(ren) —
Mark only one.
Hispanic or Latino Not Hispanic or Latino
B. Racial data of child(ren) —
Mark one or more that
apply.
Asian
White
Black or African American
American Indian or
Alaska Native
Native Hawaiian or Other
Pacic Islander
Second Child
Same Days as
Above
Same Times as Child Above Same Meals as Above
Name
Birth Date
Age
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TIME IN TIME OUT
TIMES CHILD ATTENDS
SCHOOL
Early Morning Snack
Breakfast
A.M. Snack
Lunch
P.M. Snack
Supper
Evening Snack
AM PM TIME AM PM TIME
Leaves
Center
Returns To
Center
Yes No I work multiple shifts and child(ren) may be in care
different days/hours
Name
Birth Date
Age
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TIME IN TIME OUT
TIMES CHILD ATTENDS
SCHOOL
Early Morning Snack
Breakfast
A.M. Snack
Lunch
P.M. Snack
Supper
Evening Snack
AM PM TIME AM PM TIME
Leaves
Center
Returns To
Center
Yes No I work multiple shifts and child(ren) may be in care
different days/hours
ILLINOIS STATE BOARD OF EDUCATION
Annual Enrollment Form
Child and Adult Care Food Program
This form is required for Child Care Centers, Pre-K, Head Start, Even Start, and Licensed Outside School Hours Programs.
This form is NOT required for At-Risk After-School, License-exempt Outside School Hours, or Emergency Shelters.
First Child
ISBE 67-98 (5/21) Effective July 1, 2021
6 SIGNATURE
I certify the information ___________________________________________________ ___________________________ _________________________________
above is correct. Signature of Parent or Guardian Date Telephone Number of Parent or Guardian
CHILD CARE REPRESENTATIVE USE ONLY
Effective Date of this enrollment form: _____________________________________
The effective date may be made retroactive back to the rst day the child participates in the CACFP as long as it occurs in the same month in which this form is received.
1
FULL NAME OF ENROLLED CHILD
(Include Birth Date/Age)
2
DAYS OF WEEK
IN ATTENDANCE
3
TIMES CHILD NORMALLY ATTENDS DURING WEEK
4
MEALS RECEIVED
Third Child
Same Days as
Above
Same Times as Child Above Same Meals as Above
Name
Birth Date
Age
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TIME IN TIME OUT
TIMES CHILD ATTENDS
SCHOOL
Early Morning Snack
Breakfast
A.M. Snack
Lunch
P.M. Snack
Supper
Evening Snack
AM PM TIME AM PM TIME
Leaves
Center
Returns To
Center
Yes No I work multiple shifts and child(ren) may be in care
different days/hours
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 le a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination
Complaint Form, found online at http://www.ascr.usda.gov/complaint_ling_cust.html, or at any USDA ofce, 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, Ofce of Adjudication,
1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. Individuals who are deaf, hard of hearing or have
speech 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
Parents/Centers: This institution participates in the Child and Adult Care Food Program (CACFP) and receives reimbursement to provide more nutritious meals for your
child(ren). Federal CACFP regulations require all parents or guardians to complete or review a CACFP Annual Enrollment Form when enrolling their child(ren) and every year
thereafter.This information will help ensure all children receive appropriate meals during their care. The parent or center may complete Sections 1 through 4. The parent must
review to ensure accuracy; then complete Section 5, sign and date Section 6. Section 5: this section is optional. CACFP sponsors must ensure households are made aware that
failure to provide racial or ethnic identity information will not impact their eligibility. However USDA strongly encourages CACFP sponsors to explain the importance of this data to
parents/guardians to complete this section. The center will review completed enrollment form.
Use your "Mouse" or "Tab" key to move through the fields and check boxes. After completing last field, save document to hard drive to make future updates or click print button.
