Child and Adult Care Food Program

Child Care Enrollment Form

 

   

    Where Healthy Eating Becomes a Habit

 

 

 

 

 

    YWCA of Jamestown - 401 North Main Street, Jamestown, NY 14701 - (716) 488-2237 ext. 225 - FAX: (716) 484-1752

Notice to Parents:  You may receive a telephone call to verify attendance of your child at the home of this child care provider.  A routine random audit of attendance of a small percentage of providers each month is required by the NYS Department of Health.

[FrontPage Save Results Component]

Please provide your account information:

Parent's User Name
Parent's Password
Confirm Parent's Password

Please provide Day Care Provider information:

Day Care Provider
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone --(888) 888-8888
Home Phone --(888) 888-8888
FAX --(888) 888-8888
E-mail
URL

Please identify child's information:

Child's Name
Date of Birth -- mm/dd/yy
Sex Male Female
Living Status
Days Attending M  T  W  TH  F  S  S

Time in -- hh:mm     --am/pm        Time out -- hh:mm      --am/pm

Is this child related to the provider? Yes No                     Does this child have a handicap?    Yes No

Please provide Parent/Guardian's information:

Parent/Guardian's Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone --(888) 888-8888
Home Phone --(888) 888-8888
FAX --(888) 888-8888
E-mail
URL
Date Signed -- mm/dd/yy

OFFICE USE ONLY

____ TIER 1     ____ TIER II

APPROVED MEALS: ____BREAKFAST ____ AMS ____ LUNCH ____ PMS ____ SUPPER ____ ES

DATE RECEIVED _____/_____/_____                              RENEWAL DATE _____/_____/_____
 

The YWCA is a United Way Agency

 

 

 

Web Master:  Debbie Marsh
Copyright © 2003 - YWCA of Jamestown.  All rights reserved. ywca@madbbs.com
Revised: 02/11/03