CACFP Enrollment Form

CACFP Enrollment Form
Enroll a participant in the Child and Adult Care Food Program (CACFP) by providing the required information below.
Participant's Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Participant's Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Name (if participant is a minor)
First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Program Site/Location
Does the participant have any dietary restrictions or food allergies?
Yes (please specify)
Is the participant eligible for any of the following assistance programs? (Select all that apply)
Other
Household Size
Total Monthly Household Income (before taxes)
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: