CACFP Form

Forms will be submitted to Tracie Clarke

Required *

Contact Person *

Please enter a contact

Name of Center (if applicable):

Town in which center/home is located *

Phone Number *

Email Address

How do you prefer to be contacted? Phone Email

Type of Center * Registered home provider Public Center Nonprofit Center Private Center (must have at least 25% eligible children)

On average, how many children, age 0-12, do you serve per day?

Breakfast

Morning Snack

Lunch

Afternoon Snack

Supper

Evening Snack

Remaining sections for centers only

Number of enrolled children

Licensed capacity

Percent of children eligible for free/reduced priced school meals

If you do not know the percent eligible of your children, how many receive:

60-100% child care subsidy

Some subsidy up to 60%

No subsidy

Include any comments or questions here