CHILDCARE ENROLLMENT FORM
                                    (THIS FORM IS TO BE RE-CERTIFIED ANNUALLY)


CHILD'S NAME___________________________________

DATE OF BIRTH__________________________________

ENROLLMENT DATE______________________________

WITHDRAWAL DATE______________________________

DAYS IN CARE:(MARK ALL THAT APPLY)

                 ______M-F        _________M-W-F            _________T-TH

               OTHER:_____________________________________

HOURS  IN CARE:

               START TIME__________        ENDING TIME___________

MEALS/SNACK SERVED TO CHILD IN CARE:

          ___BREAKFAST              ___AM SNACK            ___LUNCH             __PM SNACK     

*I certify that the above referenced information is true and correct to the best of my knowledge:

PARENT SIGNATURE____________________________ DATE_________ (first year enrolled)

PARENT SIGNATURE____________________________ DATE_________(second year enrolled)

PARENT SIGNATURE____________________________ DATE_________(third year enrolled)

                                                                             BUILDING FOR THE FUTURE:
THIS CHILDCARE FACILITY RECEIVES FEDERAL CASH ASSISTANCE TO SERVE HEALTHY MEALS TO YOUR CHILDREN. GOOD NUTRITION TODAY
MEANS A STRONGER TOMORROW!  MEALS SERVED HERE MUST MEET NUTRITION REQUIREMENTS ESTABLISHED BY USDA'S CHILD AND ADULT
CARE FOOD PROGRAM. IF YOU HAVE QUESTIONS OR CONCERNS PLEASE CONTACT

                                                                                    
 QUESTIONS?CONCERNS?
                                                                                                                            CALL USDA AT 1800-795-3272
                                  
                                                                                                                                                    OR

                                                                                                              FOOD AND NUTRITION AT 1800-TELL TDA
                                                                                                                                                                             (835-5832)

                                                                                                                                                    OR

                                                                                           YOUR CHILD CARE FACILITY CONTRACT ORGANIZATION AT
                                                                                                                            (817) 571-7717 / (817) 884-7334
                                                                                                                                        NICKIE SMITH
                                                                                NON-DISCRIMINATION POLICY:
JUST FOR KIDZ DOES NOT DISCRIMINATE ON THE BASIS OR RACE, COLOR, SEX,NATIONAL ORIGIN, AGE OR DISABILITY. TO FILE A COMPLAINT OF DISCRIMINATION, WRITE TO
DIRECTOR, CIVIL RIGHTS OFFICE, TEXAS HEALTH AND HUMAN SERVICES COMMISSION, P.O. BOX 13247, AUSTIN TEXAS 78711, OR THE U.S. DEPARTMENT OF AGRICULTURE (USDA),
DIRECTOR, OFFICE OF CIVIL RIGHTS, RM 326-W, WHITTEN BUILDING, 1400 INDEPENDENCE AVENUE SW, WASHINGTON D.C. 20250-9410 OR CALL (202)720-5964 (VOICE AND TDD). NOTE:
DISCRIMINATION COMPLAINTS BASED ON RELIGION OR POLITICAL BELIEF MUST BE REFERRED ONLY TO THE CIVIL RIGHTS OFFICE, TEXAS HEALTH AND HUMAN SERVICES
COMMISSION.
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