Covington Enrollment Form

CHILD'S INFORMATION

Anticipated Start Date:(Required)

Approximate Days & Hours of Attendance:(Required)

Child’s Full Name:(Required)

First Middle Last

Child’s Gender:(Required)

Age:(Required)

Date of Birth:(Required)

Child’s Address:(Required)

Street Address City State ZIP Code

Home Phone Number:(Required)

Who Does the Child Live With?(Required)

Child’s Legal Guardian(s):(Required)

MOTHER'S INFORMATION

Mother’s Full Name:(Required)

First Last

Mother’s Home Address:(Required)

Street Address City State ZIP Code

Email:(Required)

Home Phone Number:(Required)

Cell Phone Number:(Required)

Cell Provider:(Required)

Mother’s Social Security Number:(Required)

Mother’s Place of Employment:(Required)

Employer’s Address:(Required)

Street Address City State ZIP Code

Business Telephone Number:(Required)

Hours of Employment:(Required)

FATHER'S INFORMATION

Father’s Full Name:(Required)

First Last

Father’s Home Address:(Required)

Street Address City State ZIP Code

Email:(Required)

Home Phone Number:(Required)

Cell Phone Number:(Required)

Cell Provider:(Required)

Father’s Social Security Number:(Required)

Father’s Place of Employment:(Required)

Employer’s Address:(Required)

Street Address City State ZIP Code

Business Telephone Number:(Required)

Hours of Employment:(Required)

EMERGENCY CONTACTS & AUTHORIZED PICK UP RESPONSES

1ST CONTACT / PICK UP PERSON

Name:(Required)

First Last

Phone Number:(Required)

Address:(Required)

Street Address City State ZIP Code

Relationship to Child:(Required)

Not able to pick up the following children:

2ND CONTACT / PICK UP PERSON

Name:

First Last

Phone Number:

Address:

Street Address City State ZIP Code

Relationship to Child:

Not able to pick up the following children:

3RD CONTACT / PICK UP PERSON

Name:

First Last

Phone Number:

Address:

Street Address City State ZIP Code

Relationship to Child:

Not able to pick up the following children:

4TH CONTACT / PICK UP PERSON

Name:

First Last

Phone Number:

Address:

Street Address City State ZIP Code

Relationship to Child:

Not able to pick up the following children:

5TH CONTACT / PICK UP PERSON

Name:

First Last

Phone Number:

Address:

Street Address City State ZIP Code

Relationship to Child:

Not able to pick up the following children:

ADDITIONAL COMMENTS & INFORMATION

Is there any other information that would be helpful to our management and teaching staff?(Required)

DROP OFF

A Kid's World requires that all children be dropped off no later than 9am. There will be exceptions granted on an individual basis, in the event of, a scheduled appointment. If you have an appointment that would require a late drop off, you must message the center for permission prior to the appointment. We do our lunch meal counts and daily schedule at 10am. In addition, our instructional day begins at 8:30am and late drop offs can be disruptive for the teacher & class!

SIGNATURE

Parent Signature:(Required)

Date:(Required)

TUITION & FEES

• Hours of Operation: 6:30 AM - 6:30 PM

• Full tuition is due on Fridays, regardless if your child attends that Friday or not. Sickness does not excuse making your payment on Friday.

• Weekly tuition is due on Fridays by 6:30pm for the upcoming week in advance.

• If weekly tuition is not paid by Friday at 6:30pm, a fee of $25 will be charged.

• late tuition is not paid by Wednesday at 6:30pm, your child will not be allowed to return until your account is paid in full

• Due to strict DECAL requirements for teacher/student ratios, we require a written 2 week notice for enrollment changes and/or disenrollment. This allows us adequate time to make necessary staffing changes and/or enroll children to fill your spot. If you fail to provide a written two-week notice, you will be responsible for the full cost of the two weeks tuition. This is a liquidated damages clause. AKW utilizes the use of a collection agency to collect all outstanding debt. If this becomes necessary, you are responsible for the fees charged by this agency. In addition, your bad debt will be reported to appropriate credit agencies

• If you leave our center owing a balance, no records will be released until your account is paid in full. This includes, but is not limited to - financial records, child records etc.

• After 6 continuous months of enrollment, each family is allowed one week of vacation and one ½ price week annually. Vacation does not carry over from year to year. We must have two weeks of advance notice for vacation time to be granted.

• Vacation time may not be split up into days. It must be 1 full week. Your child may not attend the center during the vacation week or ½ price week.

• A Kid's World reviews tuition and fees twice per year. AKW will adjust tuition to account for market and labor variations.

• If you leave our center with any type of balance and we are forced to utilize our attorney or collection agency to collect this debt, you will be responsible for all attorney fees and collection fees incurred. Also, all interest allowable by law in the state of Georgia will also be added monthly until balance is collected.

• All parents of school-age children who ride the bus to our center in the afternoons, are required to call a minimum of one hour prior to school dismissal if his/her children will not be attending the center in the afternoon. If parent fails to notify the center of such an absence, there will be a $25.00 charge per child. A Kid's World will not leave the school until all children are accounted for daily.

• If you have a child enrolled in our school-age program and that child does not attend during a holiday week, you must pay your regular weekly price.

• Any late fee unpaid by next billing cycle, Friday, will be subject to additional late fees.

• The center closes promptly at 6:30pm. If you are late picking up your child, it is $25 for the first 10min (6:31pm-6:40pm) and $1/minute thereafter.

• If you are enrolled in our PreK Before & After Care Program, you are responsible for weekly tuition, even if, your child does not attend during Prek Holiday weeks.

Parent/Guardian Signature:

Date

HEALTH INFORMATION AND EMERGENCY PERMISSION

Child’s Full Name:(Required)

First Last

Date of Birth:(Required)

Phone Number:(Required)

Street Address:(Required)

Street Address City State ZIP Code

Parent/Guardian 1:(Required)

Phone:(Required)

Parent/Guardian 2:

Phone:

Doctor’s Name:(Required)

Phone:(Required)

Dentist’s Name:(Required)

Phone:(Required)

Health Insurance Provider:(Required)

Phone:(Required)

Insurance Member ID #:(Required)

Primary Insured’s Name & Date of Birth:(Required)

should your child become injured or ill while in the care of A Kid's World and you are unable to be contacted, A Kid's World is authorized to secure medical attention as deemed necessary. By signing below the parent acknowledges that A Kid's World does not provide medical insurance to the children in our program and the parent shall assume responsibility for any/all medical expenses. Also, by signing below you agree to hold A Kid's World and its staff members harmless to any claims that may arise during my child's enrollment in the program.

Parent’s Signature:(Required)

Date:(Required)

Does your child have physical problems, mental health disorders or developmental disabilities affecting participation in school activities?(Required)

Yes

Specify:

Does your child have allergies? (foods, medications, insects, etc.?)(Required)

Yes

Specify:

Are there any special procedures required in caring for your child?(Required)

Yes

Specify:

EMERGENCY CONTACTS:

(if parent/guardian cannot be reached)

Name:(Required)

Relationship:(Required)

Phone 1:(Required)

Phone 2:

Name:

Relationship:

Phone 1:

Phone 2:

A Kid’s World Emergency Medical Procedures:

1. Call emergency medical team, if necessary

2. Call parent/guardian

3. Call alternate emergency contact, if necessary

4. Emergency medical team transport child to hospital, if necessary

5. A Kid’s World Representative will accompany child to the hospital

Hospital A Kid’s World Uses:
Piedmont Hospital

Parent/Guardian Name:(Required)

Child Name:(Required)

Parent/Guardian Signature:(Required)

Date:(Required)

TRANSPORTATION AGREEMENT

Child’s Name:(Required)

Date of Birth:(Required)

Signature (Parent/Guardian):(Required)

Date:(Required)

TRANSPORTATION AGREEMENT FOR SCHOOL AGE USE ONLY

If the child relocates to another school or the hours change, this form must be updated.

Name of School:

School Phone:

School Address:

Street Address City State ZIP Code

• In the event the designated location is unable to receive children they will be returned to AKW

• It is vital that AKW be notified of any changes in the above scheduled transportation.

• AKW will assume the above schedule of transportation will be followed unless we receive different instructions from parents. Instructions should be received at AKW no later than 1hr prior to pick up time.

To Above Listed School at (am/pm):

From Above Listed School at (am/pm):

On the following days (Please Check All That Apply)

Monday

Tuesday

Wednesday

Thursday

Friday

PHOTO RELEASE FORM

Child's Name:(Required)

Date:(Required)

Parent/Guardian Name:(Required)

Parent/Guardian Signature:(Required)

SOCIAL MEDIA RELEASE

Child’s Name:(Required)

Parent’s Signature:(Required)

A KID’S WORLD ENTERPRISES INC. PARENT HANDBOOK ACKNOWLEDGMENT

1. Hours and Days of Operation .......................................................................................................................................................Page 1

2. Holiday Schedule ................................................................................................................................................................................Page 1

3. Inclement Weather Procedures .................................................................................................................................................Page 1

4. Drop Off & Pick Up Procedures ..................................................................................................................................................Page 1

5. Sign In/Sign Out Procedures ........................................................................................................................................................Page 1

6. Enrollment Information Requirements ................................................................................................................................Page 2

7. Immunization Form #3231 Requirement ...........................................................................................................................Page 2

8. Tuition Policies & Procedures ......................................................................................................................................................Page 2

9. Transportation Procedures & Document Requirements .............................................................................................Page 2

10. Discipline Procedures ..................................................................................................................................................................Page 2&3

11. Emergency Medical Plan.................................................................................................................................................................Page 3

12. Medication Dispersion Procedures ..........................................................................................................................................Page 3

13. Illness Policy ...........................................................................................................................................................................................Page 4

14. Infant Formula & Meal Substitution Policies .....................................................................................................................Page 5

15. USDA Food Program Requirements.........................................................................................................................................Page 5

16. Foreign Food Policy.............................................................................................................................................................................Page 5

17. Child Abuse/Neglect Policy............................................................................................................................................................Page 5

18. Photography Release .........................................................................................................................................................................Page 5

19. Center Fundraisers...............................................................................................................................................................................Page 6

20. Personal Belongings ...........................................................................................................................................................................Page 6

21. Parent Labeling Responsibility ....................................................................................................................................................Page 6

22. Inclusion Policy ......................................................................................................................................................................................Page 6

23. Potty Training..........................................................................................................................................................................................Page 6

24. Outdoor Participation........................................................................................................................................................................Page 6

25. Withdrawing From The Program................................................................................................................................................Page 6

26. Vacation Requests................................................................................................................................................................................Page 6

27. Accidental Insurance Waiver.........................................................................................................................................................Page 7

28. Play Clothing Warning.......................................................................................................................................................................Page 7

29. Telephone Payment Option & Fees...........................................................................................................................................Page 7

30. Diapering Procedures ........................................................................................................................................................................Page 7

31. Infant Feeding Plan.............................................................................................................................................................................Page 7

32. Infant Safe Sleeping Standards ...................................................................................................................................................Page 7

33. Nondiscrimination Policy ................................................................................................................................................................Page 7

34. Private Employment Acknowledgement and Release.................................................................................................Page 7

35. Bus and Parking Lot Safety ............................................................................................................................................................Page 7

36. Celebration Snacks..............................................................................................................................................................................Page 7

38. Aggressive Behavior Policy .......................................................................................................................................................Page 8&9

39. Aggressive Biting Policy..........................................................................................................................................................Page 9 &10

40. Parent Code of Conduct................................................................................................................................................................Page 10

By signing this acknowledgment, I am indicating that I have read, understand and agree to adhere to A Kid’s World policy and procedures as outlined in this handbook.

Child(ren)’s Name(s):(Required)

Guardian's Name Printed:(Required)

Guardian’s Signature:(Required)

A KID’S WORLD WITHDRAWAL NOTICE

A Kid’s World requires a two week notice for withdrawal. If you choose to disenroll your child for any reason, you MUST provide a two-week written notice. If you fail to provide this notice – you will be billed for 2 weeks from the last date of attendance. You will be responsible for payment of the notice, even if, your child did not attend.

Parent Signature:(Required)

Date:(Required)

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS

Parental Authorization. Except for first aid, personnel shall not dispense personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child’s physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parent.

Check All That Apply(Required)

Baby Wipes

Band-Aids

Neosporin or similar ointment

Bactine or similar first aid spray

Sunscreen

Insect Repellent

Non-prescription ointment (such as A & D, Destin, Vaseline)

Other

If Other, please specify:

Parent/Guardian Signature:(Required)

Date:(Required)

AUTOMATED PAYMENT PROCESSING

Safe - Convenient - Easy

We are excited to offer the safety, convenience and ease of Tuition Express®—a payment processing system that allows secure, on-time tuition and fee payments to be made from either your bank account or credit card.

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT and CREDIT CARD

COMPLETE ONE SECTION ONLY

SECTION A (Credit Card)

Cardholder Name:

Phone Number:

Cardholder Address:

Street Address City State ZIP Code

Account Number:

Expiration Date:

Cardholder Signature:

Date:

SECTION B (Bank Account)

Your Name:

Phone Number:

Address:

Street Address City State ZIP Code

Bank or Credit Union Name:

Address:

Street Address City State ZIP Code

Routing Transit Number:

Account Number:

Account Type:

Checking

Savings

Authorized Signature:

Date:

FOR OFFICIAL USE ONLY

Date Received:

Employee Signature:

WIC - A Special Food and Nutrition Education Program for Women, Infants and Children

WHO IS ELIGIBLE? » A pregnant woman » A breastfeeding woman » A woman who has recently been pregnant » An infant or a child less than 5 years old	TO BE ELIGIBLE, YOU MUST ALSO: » Have a low or moderate income AND » Have a special need that can be helped by WIC foods and nutrition counseling
APPROVED WIC FOODS: Milk, cheese, eggs, cereals, peanut butter, fruit or vegetable juices, dry beans or peas, iron fortified formula

You do not have to be on public assistance to apply. Call your local health department for more information.

GEORGIA WIC PROGRAM
Georgia Department of Public Health
2 Peachtree Street NW, 10th Floor
Atlanta, GA 30303
Telephone: 1-800-228-9173
Website: http://dph.georgia.gov/WIC

INCOME ELIGIBILITY GUIDELINES
(Effective from July 1, 2021 to June 30, 2022)

Household Size	Reduced Meal Income Limits
	Annually	Monthly	Twice A Month	Every Two Weeks	Weekly
1 …..	26,973	2,248	1,124	1,038	519
2 …..	36,482	3,041	1,521	1,404	702
3 …..	45,991	3,833	1,917	1,769	885
4 …..	55,500	4,625	2,313	2,135	1,068
5 …..	65,009	5,418	2,709	2,501	1,251
6 …..	74,518	6,210	3,105	2,867	1,434
7 …..	84,027	7,003	3,502	3,232	1,616
8 …..	93,536	7,795	3,898	3,598	1,799
For each additional family member add	+ 9,509	+793	+ 397	+366	+183

USDA FOOD PROGRAM

Dear Parents,
The USDA Food Program is a subsidized program that allows our center to provide high quality, large portioned meals to our children without any additional cost to our families.

In order for our center to qualify for this program we must prove that at least 25% of our families meet the "Free or Reduced" income standards. To do this we must maintain income verification forms on all families that attend our center. Even if you do not feel like your income would help us "qualify", we still must maintain a verification form for your family. We must update our forms every August.

Please feel sure that this information is maintained separate from children's records and only the management team had access to this information. This information is not used for any other purpose.

In addition, please complete all areas of this form! If your form is not filled out and signed, we have to count your family as a paid family regardless of your income!

Thank you for your help and understand. Please feel confident in knowing that our center's participation in the USDA Food Program allows A Kid's World to serve high quality meals to our children.

Sincerely,
Shannon Smith
Director/Owner
A Kid's World
770-786-1587

CACFP Household Letter

Dear Parent/Guardian:

This letter is intended for parents or guardians of children enrolled in a child care center. A Kid's World 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 CACFP Meal Benefit Income Eligibility Form also known as the Income Eligibility Statement (IES). 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 an Income Eligibility Statement (IES) for each of my children in day care? You may complete and submit one [1] IES 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: A Kid's World 4533 Old Hwy 138 Loganville, GA 30052 770-786-1587.
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) benefits can get free meals. Foster children and children enrolled in Head Start are also eligible for free meals. Children in households participating in WIC may be eligible for free meals.
3. Who can get reduced-price meals? Your children can get reduced-priced meals if your household income is within the reduced-price limits on the Federal Income Eligibility Guidelines, shown on 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 Eligibility Guidelines, 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 receive overtime pay, include it, but not if you only work overtime on an occasional basis.
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 Income Eligibility Statement but are not required to include payments received for the foster child as income. Households wishing to apply for such benefits for foster children should contact A Kid's World 4533 Old Hwy 138 Loganville, GA 30052 770-786-1587.
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, regarding 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. Will the information I give be verified? (pricing program only) Maybe. We may ask you to send written proof to verify the information you submitted on the form.
11. What if I disagree with the decision about the information I complete on this form? You should talk to your A Kid's World 4533 Old Hwy 138 Loganville, GA 30052 770-786-1587

In the operation of the CACFP, 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 770-786-1587

Sincerely,
Shannon Smith

The Richard B. Russell National School Lunch Act requires the information on this meal benefit form. 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 all adult household members, including the child care participant. 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, Food Distribution Program on Indian Reservations (FDPIR) or other FDPIR identifier for the participant receiving meal benefits 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 CACFP.

Non-discrimination Statement: In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P. Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:
1. mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or
2. fax:
(833) 256-1665 or (202) 690-7442; or
3. email:
program.intake@usda.gov

This Institution is an equal opportunity provider.

The participant in the day care facility may qualify for free or reduced-price meals if your household income falls within the limits on the Annual Income Eligibility Guidelines.

HOUSEHOLD SIZE

YEARLY INCOME

Please refer to the Income Eligibility Guidelines that are updated annually and available at https://www.decal.ga.gov/documentsattachments/Incomeeligibguidelines.pdf

HOUSEHOLD SIZE

YEARLY INCOME

Please refer to the Income Eligibility Guidelines that are updated annually and available at https://www.decal.ga.gov/documentsattachments/Incomeeligibguidelines.pdf

HOUSEHOLD SIZE

YEARLY INCOME

Please refer to the Income Eligibility Guidelines that are updated annually and available at https://www.decal.ga.gov/documentsattachments/Incomeeligibguidelines.pdf

HOUSEHOLD SIZE

YEARLY INCOME

Please refer to the Income Eligibility Guidelines that are updated annually and available at https://www.decal.ga.gov/documentsattachments/Incomeeligibguidelines.pdf

HOUSEHOLD SIZE

YEARLY INCOME

Please refer to the Income Eligibility Guidelines that are updated annually and available at https://www.decal.ga.gov/documentsattachments/Incomeeligibguidelines.pdf

HOUSEHOLD SIZE

YEARLY INCOME

Please refer to the Income Eligibility Guidelines that are updated annually and available at https://www.decal.ga.gov/documentsattachments/Incomeeligibguidelines.pdf

HOUSEHOLD SIZE

YEARLY INCOME

Please refer to the Income Eligibility Guidelines that are updated annually and available at https://www.decal.ga.gov/documentsattachments/Incomeeligibguidelines.pdf

HOUSEHOLD SIZE

YEARLY INCOME

Please refer to the Income Eligibility Guidelines that are updated annually and available at https://www.decal.ga.gov/documentsattachments/Incomeeligibguidelines.pdf

Each additional person

Add:

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 your child for free or reduced-price meals. You must include the social security 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 SNAP, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number for your child 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 your child is eligible for free or reduced-price meals, and for administration and enforcement of the Program.

Non-discrimination Statement: In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf , from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:
1. mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or
2. fax:
(833) 256-1665 or (202) 690-7442; or
3. email:
Program.Intake@usda.gov

This institution is an equal opportunity provider.

Sources of Income Chart1

INSTRUCTIONS
Households that receive SNAP, TANF, FDPIR, SSI or Medicaid: Complete the following:
Part I: For family day care home and child care center, list participant's name and a SNAP, TANF, or FDPIR case number. For adult day care, list participant's name and a SNAP, TANF, FDPIR, SSI or Medicaid case number. Note: foster children (children placed in the household by the court system) can be included in this section. A separate form is no longer needed for foster children. Note: Children in Foster care, enrolled in Head Start and children who meet the definition of Homeless, Migrant or Runaway are eligible for free meals. Please refer to the Q&A section for a definition of each free categorical eligibility.
Part II: Skip this part.
Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate the meals he/she normally receives while in care.
Part IV: Sign the form. A Social Security Number is not necessary.
Part V: Answer this question if you choose to.

All other Households, including WIC households, complete the following:

Part I: For family day care home, child care center or adult day care, list participant's name.
Part II: To report total household income from last month, complete the following:
A- Child Income: Please indicate the TOTAL income received by Child household members listed in PART I. Please list any child income and how often it is received in this section.
B- Adult Income: List the first and last name of each Adult person living in your household as an economic unit. You must indicate yourself and all other adult members living with you. In the case of an adult participant, the adult participant, and if residing with the adult participant, the spouse and dependent(s) of the adult participant should be listed here as well. Attach another sheet if necessary.
List Gross Income. Next to each person's name, list each type of income received last month, and how often it was received.
B-Column 1: List the gross income each person earned from work. This is not the same as take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly).
B-Column 2: List the amount each person got last month from welfare, child support, alimony.
B-Column 3: List Social Security, pensions, and retirement.
B-Column 4: List all other income sources including Worker's Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran's benefits (VA benefits), disability benefits, regular contributions from people who do not live in your household. Report net income from self-owned businesses, farming, or rental income. Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing allowance.
Social Security Number: If income is listed or completed in Part Il, the adult completing the form must also list the last four digits of his or her Social Security Number or mark the "I don't have a Social Security Number" box.
If no income: If the person does not receive income from any source, write "O". If "O" is entered or any income fields are blank, the person is certifying that there is no income to report. Please note that the last four digits of his or her Social Security Number is REQUIRED when/if Part II B is completed and household members are listed (with or without income).

Sources of Income for Children
Sources of Child income	Example(s)
Eamings from work	- A child has a regular full or part-time job where they earn a salary or wages
Social Security -Disability Payments -Survivor's Benefits	- A child is blind or disabled and receives Social Security benefits - A parent is disabled, retired, or deceased, and their child receives Social Security benefils
- Income from person outside the household	- A friend or exlended family member regularly gives a child spending money
-Income from any other source	- A child receives regular income from a private pension fund, annuity, or trust

Sources of Income for Adults
Earnings from Work	Public Assistance / Alimony / Child Support	Pensions / Retirement/ A Other Income
Salary, wages. cash bonuses - Net income from self. emplovment farm or busines(s) If you are in the US Military: - Basic pay and cash bonuses (do NOT include combat pay. FSSA or privatized housing alowances) - Alowances for off- base housing lood and clothing	-Unemployment benefits worker's compensalion - Supplemental Security Income (SSI) Cash assislance from Slate or local government - Alimony payments - Child support payments -Veteran's benefits - Strike benefits	- Social Security (including railroad retirement and black lung benefils) - Privale pensions or disability benefits - Regular income from trusis or estates - Annuities - Inveslment income - Earned interest - Rental income - Regular cash payments from oulside household

C- Total Household Members. Please list the total number of all household members (children and adults) in this section.
Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate the meals he/she normally receives while in care.
Part IV: An adult household member must complete this section completely and then sign the form. Please refer back to Part II to ensure the last four digits of his/her social security number have been recorded or the box has been marked if he/she does not have one.
Part V: Answer this question if you choose to.

Privacy Act Statement: This explains how we use the information you give us.

The Child and Adult Care Food Program

Income Eligibility Statement Form and Supporting Documents

The United States Department of Agriculture (USDA) issued revised Income Eligibility Statements (IES) and other required forms to all state agencies to disseminate to institutions participating in the Child and Adult Care Food Program (CACFP). The newly revised IES package includes the following: IES form and instructions, reduced income guidelines template with privacy and non-discrimination statement, Sharing Information with Medicaid/SCHIP letter, sample house-hold letters based on program type, and template letters to use when verifying income and reporting the results of the verification. This newly revised IES application conforms to USDA's newly released prototypes and therefore meet all legal requirements and reflect design best practices identified by USDA through focus testing and other research.

The revised IS package and supporting documents is available at http://www.decal.ga.gov/BftS/FormList.aspx?cat=CACFP.

Frequently Asked Questions

Q. What information do I issue to parents?
A. Institutions and facilities should issue the (1) IES form, reduced income guidelines with the privacy and non-discrimination statement, (2) appropriate household letter, and the (3) Sharing Information with Medicaid/SCHIP letter to parents/guardians of children/adults participating in the CACFP.

Q. Can centers/day care homes require parents/guardians to complete the IS form as part of the enrollment package?
A. Centers/day care homes can request that parents/guardians complete the form as part of the enrollment process, but centers should not require parents/guardians to complete the form nor should they have policies/practices in place that negatively impacts the prospective/current participant's enrollment if the parent declines or fails to complete or submit the form. This action would be in violation of the Program.

Q. If the parent, guardian, or adult member completing the form does not specify income but lists household members in Part II B, are the last four digits of the social security number required?
A. Yes, when a free or reduced eligibility determination is based upon Part II, whether income is specified or not specified, the last four digits of the social security number is required. As per the Privacy Act Statement, the information provided is used to determine if the child is eligible for free or reduced- price meals, and for administration and enforcement of the lunch and breakfast programs.

Q. Why is it necessary to issue the Sharing Information with Medicaid/SCHIP letter to parents?
A. Parents/guardians that do not wish to have their information shared with either Medicaid or SCHIP must complete the form and return to facility. Otherwise and when requested by Bright from the Start or the United States Department of Agriculture (USDA), parent/guardian information will be shared with Medicaid/SCHIP.

Q. Is it necessary to have three official's signatures on the new IS form-especially when the center is an independent center with only one staff person managing the CACFP?
A. No. Only one signature is required for Independent centers with only one staff person responsible for managing the CACFP. However, institutions with more than one person managing the CACFP, and center and administrative sponsors are required to have a minimum of two signatures: determining official and confirming official.

Q. What is the purpose of having a determining and confirming official signature?
A. The confirming official will review the form and ensure accuracy and completeness. IS forms are considered current and valid until the last day of the month in which the form was dated on year earlier. The date to be used to make this determination is the date in which the sponsor or institution official signs the IES form to certify eligibility of the participant.

Q. How long is the IS form considered current and valid?
A. IES forms are considered current and valid until the last day of the month in which the form was dated one year previously. The date used to make this determination is the date in which the sponsor/ independent center official or parent/guardian signs the IS form. CACFP institutions and SFSP sponsors must decide which date they will use as the effective date and apply this date to all income eligibility forms submitted on behalf of all participants. CACFP institutions and SP sponsors are required to complete the Income Eligibility - Effective Date Option Form. In addition, institutions must indicate the options chosen in Section VIlI. Recordkeeping (Item #2) of their Management Plan.

This means that sponsor and independent center officials should not request parent/guardians to complete IES forms at a specific frequency (e.g. start of each school year, every June, etc.). Request made by the sponsor or independent center official for IS form completion should be based solely on the expiration date of the IES forms.

Q. Do I send a report to Bright from the Start listing parent/guardians that want their information shared with Medicaid/SCHIP?
A. No. When instructed by USDA, Bright from the Start will request and collect data from institutions.

Q. Can this form be used for children in childcare facilities and adults in adult daycare facilities?
A. Yes.

Q. Can siblings be listed on one form?
A. Yes. Siblings from the same household can be listed on one form as long as there is space available.

Q. When do I verify parent/guardian income?
A. At the request of the United States Department of Agriculture (USDA), Bright from the Start, or any of its agents.

Q. Where can I get copies of the IS form and supporting documents?
A. Access Bright from the Start's webpage at http://www.decal.ga.gov/BftS/FormList.aspx?cat=CACFP.

Q. Can I still participate in the CACP if parents do not complete the IS form or do not return the form to my center?
A. Yes. However, children that do not have IES forms on file must be placed in the "paid" category on the roster, which will effect monthly reimbursement. Centers that are using the IS form to capture annual enrollment information will be required to use an alternate enrollment form that captures at a minimum the name of the child, normal hours and days of care and meals the child usually receives while in attendance.

Q. What if the form is completed by the parent but is not signed and dated by the sponsor or independent official. Is the form valid?
A. The form would neither be current nor valid for free or reduced price meals since the signature and date of the sponsor or independent official is the certification of the eligibility of the participant.

Q. Are households required to report changes in circumstances?
A. No, Public Law 108-265 modified the requirements related to reporting changes in income during the period of eligibility covered by the application. Households are not required to report changes in circumstances, such as increase in income, a decrease in household size, or when the household is no longer certified eligible for benefits through Supplemental Nutrition Assistance Programs (SNAP) or Temporary Assistance for Needy Families (TANF).

Q. Are temporary approvals (45 days) still required when no income is reported?
A. No. Temporary approvals previously provided for short term assistance, such as when a household experienced a temporary income reduction or when no income was reported have been eliminated, are no longer required. Now, year-long eligibility includes households that report no income on their IS forms.

Q. Can parents list some but not all of the household income received?
A. No, the IS form requests all the household income including the frequency. By signing the IS form the parent/guardian certifies that all the information on the form is true and that all income is reported and that they understand that the center or day care home will receive Federal funds based on the information listed by the parent/guardian.

Q. Do children participating in Head Start or Early Head Start need to complete additional income eligibility forms to qualify for free meals?
A. Children enrolled in federal and state-funded Head Start or Early Head Start Programs are categorically eligible to receive free meal benefits without further application or eligibility determination. Categorical eligibility means Meal Benefit Forms are not required.

Eligibility determinations for the CNPs are made on an annual basis. As long as the child is enrolled in Head Start or Early Head Start at the time the annual eligibility determination is made, all reimbursable meals served to that child may be claimed at the free rate.

Institutions, sponsors, and school food authorities may establish eligibility of all Head Start enrollees through documentation provided by the Head Start program. Forms of acceptable documentation include:

Approved Head Start application Statement of Head Start enrollment List of participants from a Head Start official

Q. If a child who is eligible for Head Start benefits also attends a child care center or day care home, is the child automatically eligible for free CACP meals at the child care facility without further application or eligibility determination?
A. Yes. All CACFP reimbursable meals served to children enrolled in Head Start or Early Head Start may be claimed at the free rate by child care centers or at Tier I rates in day care homes in which they are enrolled. Documentation of acceptable Head Start eligibility must be maintained.

Q. Are the siblings or other children who are members of a Head Start child's household also automatically eligible for free meals without further application?
A. Only children enrolled in Head Start are categorically eligible. Categorical eligibility based on Head Start enrollment does not extend to all children in the same household.

Q. Can a day care home document its eligibility for Tier I reimbursement based on the provider's own child's enrollment in a Head Start program?
A. The Improving Head Start for School Readiness Act of 2007 (Public Law 110-134) extended categorical eligibility only to children enrolled in Head Start; therefore, a child's Head Start enrollment does not extend to the provider.

Q. Are children who are enrolled in Head Start, but who are members of households that are above the Head Start income eligibility requirements, still eligible for CACFP meals at the free rate?
A. Yes. All reimbursable meals served to children enrolled in Head Start may be claimed at the free rate. Head Start serves primarily children from families with household incomes at or below the federal poverty level. However, a small proportion of children in families with household incomes above the poverty level may also be served.

Public Law 110-134 amended sections 9(b)(12)(A)(iii) and 17(c)(5) of the Richard B. Russell National School Lunch Act to make any child enrolled in Head Start categorically eligible for free meals without further application or eligibility determination.

Q. Are children enrolled in state-funded prekindergarten programs eligible for free meals?
A. Children participating in state-funded prekindergarten programs are not automatically eligible for free meals. In California, the income eligibility requirements for state-funded preschools are less stringent than the requirements for the Head Start Program. Therefore, determinations of eligibility for free meals for participants must be made on an individual basis.

Section 107 of the Child Nutrition and WIC Reauthorization Act of 2004 (Act) amended section 9(b) of the Richard B. Russell National School Lunch Act to make runaway, homeless and migrant children categorically eligible for free meal benefits under the National School Lunch and School Breakfast Programs and is effective July 1, 2004.

Q. What is the definition of homeless?
A. The term "homeless children has the meaning given to "homeless children and youths" in section 725(2) of the McKinney Vento Homeless Assistance Act (42 U.S.C. 11434a (2)).
"Homeless children" means:
1. Individuals who lack a fixed, regular, and adequate nighttime residence; and
2. Includes -

Children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks, or camping grounds due to lack of alternative adequate accommodations; are living in emergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement;
b. Children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings;
c. Children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and
d. Migratory children who qualify as homeless because they are living in circumstances described in a-c above.

Q. What is the definition of migrant?
A. Migrant family means, for purposes of CACFP eligibility, a family with children under the age of compulsory school attendance who changed their residence by moving from one geographic location to another, either intrastate or interstate, within the preceding two years for the purpose of engaging in agricultural work and whose family income comes primarily from this activity.

Q. What is the definition of runaway youth?
A. The term "runaway", used with respect to a youth, means an individual who is less than 18 years of age and who absents himself or herself from home or a place of legal residence without the permission of a parent or legal guardian. https://definitions.uslegal.com/r/runaway-youth

Q. What is the definition of Foster care?
A. Foster care means 24-hour substitute care for children placed away from their parents or guardians and for whom the state agency has placement and care responsibility. This includes, but is not limited to, placements in foster family homes, foster homes of relatives, group homes, emergency shelters, residential facilities, child-care institutions, and pre-adoptive homes. A child is in foster care in accordance with this definition regardless of whether the foster care facility is licensed and payments are made by the state or local agency for the care of the child, whether adoption subsidy payments are being made prior to the finalization of an adoption, or whether there is federal matching of any payments that are made.

SHARING INFORMATION WITH MEDICA|D/SCHIP

Dear Parent/Guardian:
If your children quality for free or reduced price meals, they may also be able to get free or low cost health insurance through Medicaid or the State Children's Health Insurance Program (SCHIP). Children with health insurance are more likely to get regular health care and are less likely to become sicK.

Because health insurance is so important to children's well-being, the law allows us to tell Medicaid and SCHIP that your children are eligible for free or reduced price meals, unless you tell us not to. Medicaid and SCHIP only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children in this health insurance program. Filling out the CACFP Meal Benefit Income Eligibility Forms does not automatically enroll your children in health insurance.

If you do not want us to share your information with Medicaid or SCHIP, fill out the form below and send it with your Income Eligibility Form to [address] by [date]. (Sending in this form will not change whether your children get free or reduced-price meals.).

If you checked no, fill out the form below.

Child's Name:

Signature of Parent/Guardian:

Today's Date:

Print Your Name:

Address

Street Address City State ZIP Code

For more information, you may call _________ at __________

CACFP Meal Benefit Income Eligibility Form Sharing Information with Medicaid/SCHIP.

ALL ABOUT ME AND MY FAMILY

Dear Family,
We welcome you and your child to our classroom community! We are eager to know you and your child better in the coming weeks. Please help us get started by sharing with us some important things about your child. We encourage you to talk with us at any time and to provide all information that may help us to teach and care for your child in a more complete way. We look forward to working together as partners in support of your child.

Child’s Name:(Required)

Date:(Required)

Completed By:(Required)

Relationship to Child:(Required)

In a few words, please describe your child:(Required)

Who is part of your child’s family? Please list names of family members and their relationship to the child:(Required)

What are some of your family traditions?(Required)

What are your child’s favorites?

Favorite toys:(Required)

Favorite songs:(Required)

Favorite foods:(Required)

Favorite activities:(Required)

Other:

Are there situations or experiences that upset your child?(Required)

What do you do to comfort him/her when he/she is upset or afraid?(Required)

How does your child communicate with you and other members of your family?(Required)

If already talking, can you understand the words he/she says?(Required)

Do you have any special concerns about your child’s development that you would like to share with us?(Required)

What questions do you have about your child’s upcoming school experience?(Required)

What do you hope your child gains from his/her experience at school?(Required)

How can we best support you in your role as parents?(Required)

How would you like to be contacted by your child’s teachers? Also, please tell us the best times to reach you for non-emergency conversations.(Required)

Any additional thoughts you would like to share?(Required)

Thank you for completing this form and returning it to the classroom!

INFANT AFFIDAVIT

(MANDATORY FOR ALL INFANTS IN CARE)

In CACFP, programs must offer a USDA approved "ready-to-feed" commercially prepared iron-fortified milk-based infant formula to infants in their care. DECAL only permits these types of commercially prepared, "ready-to-feed" formula.

To be completed by center BEFORE giving to parents:

Name of Sponsor: A Kid's World - Covington

According to USDA regulations, as an institution participating in the Child and Adult Care Food Program, I must offer to provide meals to all infants enrolled for care in my center/facility.

I, A Kid's World Covingotn, will provide the following to infants enrolled for care in my facility: Gerber Good Start Gentle (name of milk-based iron-fortified formula) and Gerber Whole Wheat Whole Grain Cereal (name of iron-fortified infant cereal)

Parents/Guardians:

Do not complete unless the center section above has been filled-in.

Name of Infant:

Please check one of the following options and sign this form:

would like the provider/center to provide the milk-based iron fortified infant formula and iron- fortified infant cereal listed above to my infant and I will provide clean, sanitized and labeled bottles daily.

I will provide the following for my infant on a daily basis:

Name of milk-based iron-fortified formula

(name of milk-based iron-fortified formula) and

Name of iron-fortified infant cereal

(name of iron-fortified infant cereal)

Parent/Guardian Signature

Date

*Any parent requesting any formula other than a USDA approved milk-based or soy-based iron fortified formula be provided to their infant or any parent who provides any formula other than a USDA approved milk-based or soy-based iron-fortified formula for their infant must provide a doctor's note indicating the required use of the formula. If a parent elects to have the center or day care home provider supply meals to their infant, the infant will be fed according to its individual feeding plan that is provided by the parent or guardian although the center or day care home provider may only claim reimbursement for no more than breakfast, lunch or supper, and a snack.

Return this form to the main office of the child care center. Page 3 (Infants only)

CACFP Mea! Benefit Income Eligibility Statement

PART l: Child(ren) or Adult enrolled to receive day care

Name

First Middle Last

SNAP, TANF, or FDPIR case number, or Client lD number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers. Write case number and proceed to Part lll.

Children in Head start, foster care and children who meet the definition of migrant, runaway, or homeless are eligible for free meals. Check all that apply. (See definitions in FAQS)

Head Start

Foster Child

Migrant

Runaway

Homeless

Name

First Middle Last

Children in Head start, foster care and children who meet the definition of migrant, runaway, or homeless are eligible for free meals. Check all that apply. (See definitions in FAQS)

Head Start

Foster Child

Migrant

Runaway

Homeless

Name

First Middle Last

Children in Head start, foster care and children who meet the definition of migrant, runaway, or homeless are eligible for free meals. Check all that apply. (See definitions in FAQS)

Head Start

Foster Child

Migrant

Runaway

Homeless

Name

First Middle Last

Children in Head start, foster care and children who meet the definition of migrant, runaway, or homeless are eligible for free meals. Check all that apply. (See definitions in FAQS)

Head Start

Foster Child

Migrant

Runaway

Homeless

Name

First Middle Last

Children in Head start, foster care and children who meet the definition of migrant, runaway, or homeless are eligible for free meals. Check all that apply. (See definitions in FAQS)

Head Start

Foster Child

Migrant

Runaway

Homeless

PART ll: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part l.)

Are you unsure what income to include here? Flip the page and review the charts titled "Sources of income" for more information.

A. Child lncomel - Sometimes children in the household earn or receive income. Please indicate the TOTAL income received by child household members listed in PART I here.

Child Income

How often?

(i.e., weekly, monthly, etc.)

B. Other Household Members. List all household members even if they do not receive income. Also, list the adult participant if he/she did not meet eligibility in Part I. For each Household Member listed, if they do receive income, report total gross income (before taxes) for each source in whole dollars (no cents) only along the frequency i.e., twice a month, weekly, etc. If they do not receive income from any source, write 'O'. If you enter "" or leave any field blank you are certifying (promising) there is no income to report.

Name of Other Household Member

First Last

1. Earnings from work before deductions

How often?

2. Subsidies, child support, alimony

How often?

3. Social Security, pensions, retirement

How often?

4. All other income

How often?

C. Total Household Members (Adults and Children) listed in Part I and Part ll

Social Security Number. If Part II B is completed and household members are listed (with or without income), the adult completing the form must also list the last four digits of his or her Social Security Number or check the "I don't have a Social Security Number" box below. (See Privacy Act Statement on next page). Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility.

Last four Digits of Social Security Number

I do not have a Social Security Number

PART III: Enrollment Information:

Children Only

My child is normally in attendance at the facility between the hours of

[am/pm]

Check here if only before/after school care is provided.

Circle the days your child will normally attend the center

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Circle the meals your child will normally receive while in care

Breakfast

AM Snack

Lunch

PM Snack

Supper

Evening Snack

PART IV: Signature

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 purposefully give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. This signature also acknowledges that the child(ren) or adult listed on the form in Part I are enrolled for care. If not completed fully and signed, the participant will be placed in the Paid category.

Signature

Print Name:

Date

Address

Street Address City State ZIP Code

Phone

*This application is a revision of USDA's newly released meal benefit pro t practices identified by USDA through focus testing and other research.

PART V: Participant's Ethnic and Racial ldentities: The use of rociol ond ethnic dota is to ensure compliance with USDA nondiscriminotion rcquirements onty. Ptoviding inlormotion in Part v is voluntory. Your response or lock of response will not impoct the porticipdnt's eligibility Ior medls.

PART V: Participants' Ethnic and Racial identities: The use of racial and ethnic data is to ensure compliance with USDA nondiscrimination requirements only. Providing information in Part v is voluntary. Your response or lack of response will not impact the participant's eligibility or meals.

Check one ethnic identity:

Hispanic/ Latino

Not Hispanic/ Latino

Check one or more racial identities:

American Indian or Alaskan Native

Asian

Black or African America

Hawaiian or other Pacific Islander

White

Multiracial

Official Use Only Section for Provider:

Annual lncome Conversion: Weekly x 52, Every 2 weeks x 26, Twice a month x 24, Monthly x 12

Total income: ____________________________________ Per: □ Weekly □Every 2 weeks □ Twice a month □ Monthly □ Yearly

Categorical Eligibility: check if applicable □ Eligibility: check one □ Free □ Reduced □ Paid

Day Care Homes Only: check one □ Tier ☐ Tier ll

When more than one person is performing CACFP duties, there must be at least two signatures on this form: one signature from the Determining Official (the official who determined initial income classification) and one signature from the Confirming Official (the official who verified the form's accuracy).

Determining Official's Signature: __________________________________________________ Date: ______________________________

Confirming Official's Signature: __________________________________________________ Date: ______________________________

Follow Up Official's Signature: __________________________________________________ Date: ______________________________

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Covington Enrollment Form

CHILD'S INFORMATION

MOTHER'S INFORMATION

FATHER'S INFORMATION

EMERGENCY CONTACTS & AUTHORIZED PICK UP RESPONSES

ADDITIONAL COMMENTS & INFORMATION

DROP OFF

SIGNATURE

TUITION & FEES

HEALTH INFORMATION AND EMERGENCY PERMISSION

EMERGENCY CONTACTS:

TRANSPORTATION AGREEMENT

TRANSPORTATION AGREEMENT FOR SCHOOL AGE USE ONLY

PHOTO RELEASE FORM

SOCIAL MEDIA RELEASE

A KID’S WORLD ENTERPRISES INC. PARENT HANDBOOK ACKNOWLEDGMENT

A KID’S WORLD WITHDRAWAL NOTICE

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS

AUTOMATED PAYMENT PROCESSING

WIC - A Special Food and Nutrition Education Program for Women, Infants and Children

USDA FOOD PROGRAM

CACFP Household Letter

Sources of Income Chart1

The Child and Adult Care Food Program

SHARING INFORMATION WITH MEDICA|D/SCHIP

ALL ABOUT ME AND MY FAMILY

INFANT AFFIDAVIT

To be completed by center BEFORE giving to parents:

Parents/Guardians:

Return this form to the main office of the child care center. Page 3 (Infants only)

CACFP Mea! Benefit Income Eligibility Statement

PART l: Child(ren) or Adult enrolled to receive day care

PART ll: Report income for ALL Household Members (Skip this step if participant is categorically eligible as documented in Part l.)

C. Total Household Members (Adults and Children) listed in Part I and Part ll

PART III: Enrollment Information:

PART IV: Signature

PART V: Participant's Ethnic and Racial ldentities: The use of rociol ond ethnic dota is to ensure compliance with USDA nondiscriminotion rcquirements onty. Ptoviding inlormotion in Part v is voluntory. Your response or lock of response will not impoct the porticipdnt's eligibility Ior medls.

Official Use Only Section for Provider:

Walnut Grove

Covington

Have Questions?

BRANFORD – 203-488-5437

CHESHIRE – 203-271-1147

WALLINGFORD – 203-269-5437