Child and Adult Care Food Program Intake Form

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Child and Adult Care Food Program Intake Form

Institution Name: *

Institution's Mailing Address: *

County: *

Name of Director or Main Contact:
*

Director or Main Contact’s Email Address:
*

Director or Main Contact’s Phone Number:
*

FEIN: *

The tax ID number (FEIN) is required for participation.

Type of Agency: *

For-profit

Nonprofit

Other:

Is your institution open and running? *

Yes

If your institution has not opened yet, when will it be up and operating?

Is the site(s) licensed with the Colorado Department of Early Childhood (CDEC)?
*

A child care license is required for participation in the CACFP.

Yes

Do you have more than one site? *

Yes

Which type of care do you provide? *

Child and Infant Care

Adult Daycare Center

Afterschool Program

Headstart or Early Headstart

Homeless/Emergency Shelter

School Food Authority

How did you hear about the CACFP? *

The internet or CACFP website.

State agency staff.

Word of mouth from someone you know.

Nutrition or early childhood event/conference.

Other:

What aspects of CACFP interests you?
*

Nutrition education to support healthy development of young children.

Money to cover the cost to prepare food.

Improve quality of childcare.

Other:

Required

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