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Kids Cafe CACFP Application 
The following items must be included with the application to be eligible for review for Freestore Foodbank Partnership:
* Kids Cafe CACFP Agreement
*Separate Entity Form
*Background check form
*CACFP Site Notification Form

Forms can be found here:  https://freestorefoodbank.org/kids-cafe/

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Email *
Site Information 
Site Name  *
Street Address *
Mailing Address *
Site Administrator Name *
Site Administrator email *
Site Facility phone number *
Site Administrator phone number *
Site Administrator title *
Back up contact
 *
Back up contact title *
Back up email *
Back up contact phone number *
Operating Information
First day of meal service *
MM
/
DD
/
YYYY
Last day of meal service *
MM
/
DD
/
YYYY
Site Type (Check all that apply) *
Number of meals served per day *
Select the grade groups served by your center *
Date of most recent Health Inspection 
MM
/
DD
/
YYYY
Date of most recent Fire Inspection
MM
/
DD
/
YYYY
County of Health Department *
Expiration date  *
MM
/
DD
/
YYYY
Risk level  *
Months of Operation (Check all that apply) *
Required
Site Operating Hours start time *
Time
:
Site Operating hours end time  *
Time
:
Meal Service days and times 
*Meal days and times may not be changed throughout the school year without approval from FSFB and Ohio Department of Education first.  Changing days and times without approval will result in removal from the Program. 

Only fill out the days below relevant to you.

Type your name below to acknowledge this statement:
Meal Service days and times acknowledgement  *
Monday meal start time 
Time
:
Monday meal end time 
Time
:
Tuesday meal start time 
Time
:
Tuesday meal end time
Time
:
Wednesday meal start time
Time
:
Wednesday meal end time
Time
:
Thursday meal start time
Time
:
Thursday meal end time
Time
:
Friday meal start time
Time
:
Friday meal end time
Time
:
List any educational or enrichment activities provided - must list a minimum of 2 *
Meal site School District  *
Meal site Local School  *
Meal site free and reduced lunch eligibility % *
Ethnicity and Racial Data 
Geographic Area
Enter percentages for participants served below
Hispanic %: *
Non-Hispanic %: *
Participation Area
Enter number of participants served below
Hispanic: *
Non-Hispanic: *
Geographic Area
Enter percentages for participants below - for demographic information for your area click here: https://www.census.gov/
American Indian or Alaskan Native %:  *
Asian *
Black or African American *
Native Hawaiian or Pacific Islander *
White *
Participation Area
Enter number of participants below - for demographic information for your area click here: https://www.census.gov/
American Indian or Alaskan Native *
Asian *
Black or African American *
Native Hawaiian or Pacific Islander *
White *
Explain any differences between the percentages entered for the geographic area served by the center and the percentages entered for actual center enrollment

 *
Does your location have access to a refrigerator? *
Required
Does your location have access to any of the following? *
Required
Special instructions for delivery driver *
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