Child Care Food Program Enrollment Roster

Child's Full Name

First NameLast Name

Child's Date of Birth

Date

Parent/Guardian Full Name

First NameLast Name

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Does your child have any food allergies or dietary restrictions?

Classroom / Group Name

Enrollment Date

Date

Days Attending

List of persons authorized to pick up the child (include full names and relationship to child)