Enrollment Form

* Required Information

STUDENT INFORMATION

Child's Full Name *

Date of Birth *

Sex *

Social Security Number

Primary Language *

PARENTAL CONTACT

Full Name *

Home Phone *

Address *

Work / Cell Phone

Employers Name and Address

Additional / Emergency Contacts-Complete for persons authorized to pick-up child, as by state regulations.

Emergency Contact 1

Full Name *

Relationship *

Address *

Driver's License *

Home Phone *

Work / Cell Phone

Permission to pick up child *

Yes

Contact in an Emergency *

Yes

Emergency Contact 2

Full Name

Relationship

Address

Driver's License

Home Phone

Work / Cell Phone

Permission to pick up child

Yes

Contact in an Emergency

Yes

Emergency Contact 3

Full Name

Relationship

Address

Driver's License

Home Phone

Work / Cell Phone

Permission to pick up child

Yes

Contact in an Emergency

Yes

Emergency Contact 4

Full Name

Relationship

Address

Driver's License

Home Phone

Work / Cell Phone

Permission to pick up child

Yes

Contact in an Emergency

Yes

MEDICAL INFORMATION

Doctor

Phone

Health Insurance Carrier

Address

Policy Number

Medical Release

I give permission to Kids Haven Learning Center to make whatever emergency (i.e.: first aid, disaster, evacuation) measures are judged necessary for the care and protection of my child while under the supervision of the center.

In cases of medical emergency, I understand that my child will be transported to Wellstar Hospital at Kennestone. By the local emergency unit for treatment if the local emergency resource (police, EMT) deems it necessary.

It is understood that in some medical situations the staff will need to contact the local emergency resource before the parent, child’s physician and or other adult acting on the parent’s behalf.

Emergency Medical Information

Drug Allergies/Special Medication Needs

Chronic Diseases/Other Health Problems

Parent's Signature *

Date *

Has your child ever been in a childcare setting? *

Yes

If so, what kind?

Briefly describe your child’s experience. *

Does your child have any existing conditions of which Kids Haven should be aware? *

Yes

If yes, explain

Is your child able to fully participate in all of the activities offered by Kids Haven? *

Yes

If yes, explain

Does your child function at an age appropriate level? *

Yes

If yes, explain

Can your child effectively communicate his or her needs? *

Yes

If yes, explain

Is your child on a special or restricted diet, or have any food allergies (e.g. peanut butter)? *

Yes

If yes, explain

Does your child have any non-food allergies (e.g. bee stings) *

Yes

If yes, explain

Does your child have any problems at mealtime? *

Yes

If yes, explain

Does your child rest in the middle of the day? *

Yes

Is your child toilet trained? *

Yes

If so, do they need assistance?

Does your child require any medication, therapy, medical treatment or assessment while in childcare? *

Yes

If yes, explain

Does your child use any special equipment, such as a breathing machine, wheelchair, hearing aid, braces, etc.? *

Yes

If yes, explain

Kids Haven Learning Center is dedicated to providing quality childcare for your children. The Center serves children six (6) weeks through three (3) years in full day care. We serve children four (4) years through twelve (12) years old in Pre-K, Holidays, Summer Camp Programs and in our before and after school care.

ENROLLMENT FEES AND WEEKLY TUITION

• I understand that my weekly tuition fee of $ is due on Monday of each week. If tuition is not received by close of business on Monday, a late fee of $10 will be added to my child’s tuition. A $50 registration fee is due at time the child is enrolled in the Center. A $50 renewal fee is due each year the student is enrolled in the program.

• If child is not pick up by the time the Center is closed, I agree to pay a per child late fee at $1 per minute due immediately at pick up. Our hours of operation are 6:30 a.m. to 6:30 p.m.

• I agree to pay a return check fee of $35.00 for any checks returned.

• A full weekly fee will be charged for any full time student present at Kids Haven Learning Center during any day of the week. A deposit of half the weekly tuition rate is due if the child does not attend for the week. You are allowed a free week after being enrolled for six months.

HOLIDAY CLOSINGS Our center is officially closed on the following holidays:
New Year’s day / Labor Day / Martin Luther King Jr. / Memorial Day / Independence Day
Thanksgiving and the day after / Christmas Day

ADDITIONAL POLICIES

1. In Accordance with the State of Georgia licensing regulations, we must have a complete set Immunization Records.

2. If a child has been exposed to a dangerous disease he/she should be kept at home and the facts of his/her conditions should be reported to the Center. Strep throat, pin worms, viral infections, infected ears and or glands, measles, mumps, chicken pox, scarlet fever, etc. are amongst those conditions categorized as “highly contagious”. Before a child is returned to the Center a physician release is required.

3. Kids Haven Learning Center will provide for children eating food, nutritionally balanced meals for breakfast, lunch and snacks. Water is available to children at all times. The Center is regulated by Bright from the Start (BFTS) Child and Adult Food Program (CACFP). This program is regulated by the US Department of Agriculture (USDA). Forms are provided in this enrollment packet and should be submitted along with the enrollment forms.

4. It is important for parents to provide us with telephone numbers and emergency contact.

5. Posted throughout the Center are Parent Information boards to foster better communications about your child’s daily activities.

6. Every child must have a change of clothing that is left in the center to be used for emergencies. All clothing must be labeled with the child’s name. The center is not responsible to lost clothing. For your child’s protection. Please make sure students are wearing closed toe shoes. No sandals, flip flops, cowboy boots or jelly beans shoes are allowed.

7. Kids Haven provides Developmentally Appropriate toys for each age group. We therefore ask that you not bring in toys or other personal belongings such as jewelry, money, or snacks to the center. The center is not responsible for any lost items brought from home.

8. Kids Haven will administer only dated, labeled, prescribed medications (physician prescribed non-prescription medications) at mid-day. An additional dose may be given when specifically prescribed by the physician. All medication policies are subject to state regulation. Authorization will be required by the center before the administration of any medicine. The number, dosage, the dates to be given, the time the medication is to be given and the signature of the parent.

9. Should the management at Kids Haven determine in its sole discretion that my child has not adjusted to the daily program; the child may be disenrolled and this agreement will be terminated at the option of Kids Haven. Parents will be given one (1) weeks’ notice of the disenrollment.

10. Pick up from public schools is provided by Kids Haven. If your child does not need transportation, parents must notify the center at least two (2) hours before the scheduled pickup time. Violation of this policy will result in a warning, then the withdrawal of the child.

11. One (1) hour after opening and one (1) hour before closing children are combined with mixed ages and then separated into their classes which provide developmentally appropriate activities. Parents are invited to visit the center at any time.

12. It is a Georgia Law that any unusual physical markings on a child are to be reported to the Department of Family and Children Services. The department may send an investigator. Please understand that an accusation is not being made. It is in the best interest of all children that educators and administrators be required to report. Kids Haven is not allowed to conduct an investigation first. In 1990 several public school teachers were charged with “failure to report.” That incident has made noncompliance a risky proposition. All Kids Haven employees are mandated reporters and have been informed of their legal obligation.

I certify that I have received, read and understand the information in the Enrollment Agreement.

Signature of the Parent/Guardian *

Date *

Parental Agreements with Child Care Facility

The agrees to provide day care for on , beginning at AM and ending at PM from to .

My child will participate in the following meal plan (circle applicable meals and snacks):

Breakfast Snack / Morning Snack / Lunch / Afternoon
Evening Snack / Dinner / Bedtime Snack

• Before any medication is dispensed to my child, I will provide a written authorization, which includes: Date, Name of Child, Name of Medication, Prescription Number (if any), Dosages, and Date and Time of Day to be given to child. Medicine will be in the original container with my child’s name marked on it.

• My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person(s) authorized by parent(s), or facility personnel.

• I acknowledge it is my responsibility to keep my child’s records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child’s physician, child’s health status, infant feeding plans, and immunization records, etc.

• The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

• agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.

• I authorize the child care facility to obtain emergency medical care for my child when I’m not available.

• I have received a copy and agree to abide by the policies and procedures for the above-named facility.

Signature of the Parent/Guardian *

Date *

Signature Facility Administrator / Authorized Person *

Date *

VEHICLE EMERGENCY MEDICAL INFORMATION

Child's Name *

Date of Birth *

Address *

Father's Name *

Home Phone *

Work Phone

Mother's Name *

Home Phone *

Work Phone

Person to notify in an emergency and parents cannot be reached:

Name *

Phone *

Child's Doctor *

Phone *

Child's Allergies

Current prescribed medication

Child's special needs and conditions

KIDS HAVEN LEARNING CENTER uses Kennestone Hospital located at
3950 Campbell Hill Road
Marietta, GA 30001
(770) 793-5000
• In the event of an emergency involving my child, and if Kids Haven Learning Center cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child.

Child's Name *

Signature (Parent/Guardian) *

Witness by *

Date *

Authorization to Dispense External Preparations 590-1-1-.20(1)

• Parental Authorization. Except for first aid, personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child's physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parent.
• I give, permission to apply one or more of the following topical ointments/preparations to my child in accordance with the directions on the label of the container.

Other (Please Specify)

Signature of the Parent/Guardian *

Date *

Building for the Future
MEALS
• This day care facility participates in the Child and Adult Care Food Program (CACFP), a Federal program that provides healthy meals and snacks to enrolled participants receiving care.

• Providers receive monetary reimbursement for serving nutritious meals that meet USDA requirements. The program plays a vital role in improving the quality of day care and making it more affordable for low-income families.

• CACFP homes and centers follow meal requirements established by USDA.

Breakfast	Lunch or Supper	Snacks (Two of the four groups)
Milk	Milk	Milk
Fruit or Vegetable	Meat or meat alternate	Meat or meat alternate
Grains or Bread	Grains or bread	Grains or bread
	Two different servings of fruits or vegetables	Fruit or vegetable

Participating Facilities

• Many different homes and centers operate the CACFP and share the common goal of bringing nutritious meals and snacks to participants. Participating facilities include:

• Child Care Centers: Licensed or approved public or private nonprofit child care centers, Head Start programs, and for-profit centers.

• Adult Care Centers: Public or private non-profit and some for-profit centers.

• Family Day Care Homes: Licensed or approved private child care homes.

• Afterschool Care Programs: Centers in low-income areas provide free snacks to school-age children and youth.

• Emergency/Homeless Shelters: Shelters that provide residential and food services to homeless children. Shelters are the only residential programs that may participate.

Eligibility

State agencies reimburse facilities that offer non-residential day care to the following:
• children age 12 and under;

• migrant children age 15 and younger;

• youths through age 18 in afterschool care programs in needy areas;

• chronically impaired disabled adults 18 years of age or older; or

• persons 60 years of age or older in a group setting outside their home.

Contact Information

This center participates on the CACFP under the sponsoring organization listed below. The CACFP is administered in every state and in Georgia by the agency listed below. Contact one of the following for questions about the CACFP.

Sponsoring Organization/Center

Name

Address

Contact Number

Bright from the Start: Department of Early Care and Learning Nutrition Services
2 Martin Luther King, Jr. Dr., SE Atlanta, GA 30334
404-656-5987
www.decal.ga.gov
This institution is an equal opportunity provider.

WIC
A Special Food and Nutrition Education Program For Women, Infants and Children

WHO IS ELIGIBLE?

✓ A pregnant woman

✓ A breastfeeding woman

✓ A woman who has recently been pregnant

✓ An infant or a child less than 5 years old

SERVICES PROVIDED:

✓ Nutritious foods

✓ Nutrition counseling

✓ Breast feeding support

✓ Health care referral

TO BE ELIGIBLE, YOU MUST ALSO:

✓ Have a low or moderate income

AND

✓ Have a special need that

can be helped by WIC

foods and nutrition counseling

APPROVED WIC FOODS:

✓ Milk, cheese, eggs,

cereals, peanut butter,

fruit or vegetable juices,

dry beans or peas, iron

fortified formula

Georgia WIC Program
Georgia WIC
Georgia Department of Public Health
2 Peachtree Street, NW
10th Floor
Atlanta, GA 30303
Telephone: 1-800-228-9173
Website: http://dph.georgia.gov/WIC

INCOME ELIGIBILITY GUIDELINES
(Effective from July 1, 2018 to June 30, 2019)

Household size Reduced Meal Income Limits

Annually Monthly Twice A Month Every Two Weeks Weekly

1 22,459 1,872 936 864 432

2 30,451 2,538 1,269 1,172 586

3 38,443 3,204 1,602 1,479 740

4 46,435 3,870 1,935 1,786 893

5 54,427 4,536 2,268 2,094 1,047

6 62,419 5,202 2,601 2,401 1,201

7 70,411 5,868 2,934 2,709 1,355

8 78,403 6,534 3,267 3,016 1,508

For each additional family member add + 7,992 + 666 + 333 + 308 + 154

Dear Parent/Guardian:

Young children need healthy meals to learn. This letter is intended for parents or guardians of children enrolled at either a child care center or a family day care home. Kids Haven offers healthy meals to all enrolled children as part of our participation in the U.S. Department of Agriculture’s (USDA) Child and Adult Care Food Program (CACFP). Therefore we do not allow food brought from home, unless it is due to medical reasons, however, we do make substitution due to allergies or special diet. The CACFP provides reimbursements of the CACFP by completing the attached Income Eligibility Statement form. In addition, by filling out this form, we will be able to determine if your child (ren) qualifies for free or reduced price meals. Below are answers to common questions about the Program:

1. Do I need to fill out an IES form for each adult in day care? Yes. Complete and submit one IES form for each child in your household that is enrolled in a day care center or family day care home. We cannot approve a form that is not complete, so be sure to read the instructions carefully and fill out all required information. Return the completed form to: Kids Haven 5480 Bells Ferry Rd. Acworth, Georgia 30102 (770) 926-4937. If your child(ren) is/are enrolled in a family day care home, please do not return this form to your family day care provider.

2. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Income Chart, should on this application.

3. May I fill out a form if someone in my household is not a U.S. Citizen? Yes. You or your children do not have to be U.S. citizens to qualify for meal benefits offered at the center or day care home.

4. Who should I include as members of household? You must include all people in your household, related or not (such as grandparents, other relatives, or friends who live with you). You must include yourself and all children who live with you.

5. How do I report income information and changes in employment status? The income you report must be the total gross income listed by source for each household member received last month. If last month’s income does not accurately reflect your circumstances, you may provide a projection of your monthly income. If no significant change has occurred, you may use last month’s income as a basis to make this projection. If you household’s income is equal to or less than the amounts indicated for your household’s size on the attached Income Chart, the family day care home or center will receive a higher level of reimbursement. Once properly approved for free or reduced price benefits, whether through income or proof of benefits as supported by a current Food Stamp, Temporary Assistance for Needy Families (TANF) or Food Distribution Program on Indian Reservations (FDPIR) case number, you will remain eligible for those benefits for a period not to exceed 12 months. You should, however, notify us if you or someone in your household becomes unemployed and the loss of income during the period of unemployment causes your household income to be within the eligibility standards.

6. What if my income is not always the same? List the amount that you normally get. For example, if you normally get $1000 each month, but you missed some work last month and only got $900, put down that you get $1000 per month. If you normally get overtime, include but not if you only get it sometimes.

7. What if I have foster children? In certain cases foster children are eligible for free or reduced-price meals regardless of the income of such household with whom they reside. Households wishing to apply for benefits for foster children should contact Kids Haven, 5480 Bells Ferry Rd. Acworth, GA (770) 926-4937.

8. We are in the military. Do we include our housing allowance as income? If your housing is part of the Military Housing Privatization Initiative and you receive the Family Subsistence Supplemental Allowance, do not include these allowances as income. Also, in regard to deployed service members, only that portion of a deployed service member’s income made available by them or on their behalf to the household will be counted as income to the household. All other allowances must be included in your gross income.

9. (Centers with Pricing Programs only) Will the information I give be verified? Maybe. We may ask you to send written proof to verify the information you submitted on the form. What if I disagree with the decision about the information I complete on this form? You should talk to your sponsoring organization. You may ask for a hearing by calling or writing to: Kids Haven 5480 Bells Ferry Rd. Acworth, GA (770)926-4937. In the operation of the CACFP, no person will be discriminated against because of race, color, national origin, sex, age, or disability.

If you have any questions or need help, call (770) 926-4937.

Yaw Afful

Owner

Bright from the Start: Georgia Department of Early Care and Learning
Child Adult Care Food Program
Income Eligibility Statement

PART I: Child(ren) or Adult enrolled to receive day care

Person 1

Last Name *

First Name *

Middle Initial *

Food Stamp, TANF, or FDPIR case number, Assistant Unit (AU), or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers.

Head Start Participant or Foster Child
Head Start Participant Foster Child

Person 2

Last Name

First Name

Middle Initial

Food Stamp, TANF, or FDPIR case number, Assistant Unit (AU), or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers.

Head Start Participant or Foster Child
Head Start Participant Foster Child

Person 3

Last Name

First Name

Middle Initial

Food Stamp, TANF, or FDPIR case number, Assistant Unit (AU), or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers.

Head Start Participant or Foster Child
Head Start Participant Foster Child

Person 4

Last Name

First Name

Middle Initial

Food Stamp, TANF, or FDPIR case number, Assistant Unit (AU), or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers.

Head Start Participant or Foster Child
Head Start Participant Foster Child

Person 5

Last Name

First Name

Middle Initial

Food Stamp, TANF, or FDPIR case number, Assistant Unit (AU), or Client ID number for children only. All the above, or SSI or Medicaid case number for Adults. Note: Do not use EBT numbers.

Head Start Participant or Foster Child
Head Start Participant Foster Child

PART II:

A. Name(List everyone in household, including foster and non-foster children)

Name *

B. Gross income and how often it is receivedExample: $100/monthly, $100/twice a month, $100/every other week, $100/weekly

Earnings from work before deductions

Welfare, child support, alimony

Social Security, pensions, retirement

All other income

Check if No Income

A. Name(List everyone in household, including foster and non-foster children)

Name

B. Gross income and how often it is receivedExample: $100/monthly, $100/twice a month, $100/every other week, $100/weekly

Earnings from work before deductions

Welfare, child support, alimony

Social Security, pensions, retirement

All other income

Check if No Income

A. Name(List everyone in household, including foster and non-foster children)

Name

B. Gross income and how often it is receivedExample: $100/monthly, $100/twice a month, $100/every other week, $100/weekly

Earnings from work before deductions

Welfare, child support, alimony

Social Security, pensions, retirement

All other income

Check if No Income

A. Name(List everyone in household, including foster and non-foster children)

Name

B. Gross income and how often it is receivedExample: $100/monthly, $100/twice a month, $100/every other week, $100/weekly

Earnings from work before deductions

Welfare, child support, alimony

Social Security, pensions, retirement

All other income

Check if No Income

A. Name(List everyone in household, including foster and non-foster children)

Name

B. Gross income and how often it is receivedExample: $100/monthly, $100/twice a month, $100/every other week, $100/weekly

Earnings from work before deductions

Welfare, child support, alimony

Social Security, pensions, retirement

All other income

Check if No Income

PART III: ENROLLMENT INFORMATION: Children Only

My child is normally in attendance at the facility between the hours of

To

Check here if only before/after school care is provided.

Check all that apply
Monday Tuesday Wednesday Thursday
Friday Saturday Sunday

My child will normally receive the following meals while in care:

Check all that apply
Breakfast AM Snack Lunch
PM Snack Supper Evening Snack

PART IV: Social Security Number (Adult must sign)

An adult household member must sign this form. If Part II is completed the adult signing the form must also list his or her Social Security number or mark the "I don’t have a Social Security Number" box.

I certify that all information on this form is true and that all income is reported. I understand that the center or day care home will get Federal funds based on the information I give. I understand that CACFP officials may verify the information. I understand that if I purposefully give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted. This signature also acknowledges that the child(ren) listed on the form in Part I are enrolled for care.

Print Name *

Date *

Address *

City *

State *

Zip *

Phone *

Last four Digits of Social Security Number

I do not have a Social Security Number

PART V: Participant’s ethnic and racial identities (optional)

Mark one ethnic identity
Hispanic/ Latino Not Hispanic/ Latino

Mark one or more racial identities
Asian
White
Black or African American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander

Official Use Only: Annual Income Conversion: Weekly x 52, Every 2 weeks x 26, Twice a month x 24, Monthly x 12

Total income

Per
Week Every 2 weeks Twice a month
Month Year

Household Size

Categorical Eligibility

Date withdrawn

ELIGIBILITY:

Free

Reduced

Paid

Tier I

Tier II

TEMPORARY:

Free

Reduced

Time Period

Expires after (how many days)

Determining Official's Name *

Date *

Confirming Official's Name *

Date *

Follow Up Official's Name *

Date *

The participant in the day care facility may qualify for free or reduced price meals if your household income falls within the limits on this chart.

Household Size

Yearly Income

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the social security of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Food Stamp, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number for your child or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the Program.

Non-discrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint filing cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; fax: (202) 690- 7442; or email: program.intake@usda.gov.

This institution is an equal opportunity provider.

INSTRUCTIONS

Households that receive Food Stamps, TANF, FDPIR, SSI or Medicaid: Complete the following:

Part I: For family day care home and child care center, list participant’s name and a Food Stamp, TANF, or FDPIR case number. For adult day care, list participant’s name and a Food Stamp, TANF, FDPIR, SSI or Medicaid case number.
Note: foster children (children placed in the household by the court system) can be included in this section. A separate form is no longer needed for foster children.
Part II: Skip this part.
Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate the meals he/she normally receives while in care.
Part IV: Sign the form. A Social Security Number is not necessary.
Part V: Answer this question if you choose to.

All other Households, including WIC households, complete the following:
Part I: For family day care home, child care center or adult day care, list participant’s name.
Part II: To report total household income from last month, complete the following:
Column A-Name: List the first and last name of each person living in your household as an economic unit. You must indicate yourself and all children living with you (including foster and non-foster children). In the case of an adult participant, the adult participant, and if residing with the adult participant, the spouse and dependent(s) of the adult participant. Attach another sheet if necessary.
Column B-Gross Income last month and how often it was received: Next to each person’s name, list each type of income received last month, and how often it was received.
Box 1: List the gross income each person earned from work. This is not the same as take-home pay. Gross income is the amount earned before taxes and other deductions. The amount should be listed on your pay stub, or your boss can tell you. Next to the amount, write how often the person got it (weekly, every other week, twice a month, or monthly).
Box 2: List the amount each person got last month from welfare, child support, alimony.
Box 3: List Social Security, pensions, and retirement.
Box 4: List all other income sources including Worker’s Compensation, unemployment, strike benefits, Supplemental Security Income (SSI), Veteran’s benefits IVA benefits), disability benefits, regular contributions from people who do not live in your household. Report net income from self-owned businesses, farming, or rental income. Next to the amount, write how often the person got it. If you are in the Military Housing Privatization Initiative do not include this housing allowance.
Column C-Check if no income: If the person does not have any income, check the box.
Part III: Child care centers only. Provide the normal days and hours your child is in attendance in the center and indicate the meals he/she normally receives while in care.
Part IV: An adult household member must sign the form, and list the last four digits of his/her social security number.
Or, mark the box if he/she does not have one.
Part V: Answer this question if you choose to.
Privacy Act Statement: This explains how we use the information you give us.

The Child and Adult Care Food Program
Income Eligibility Statement Form and Supporting Documents

The United States Department of Agriculture (USDA) issued revised Income Eligibility Statements (IES) and other required forms to all state agencies to disseminate to institutions participating in the Child and Adult Care Food Program (CACFP). The newly revised IES package includes the following: IES form and instructions, reduced income guidelines template with privacy and non-discrimination statement, Sharing Information with Medicaid/SCHIP letter, sample house-hold letters based on program type, and template letters to use when verifying income and reporting the results of the verification. The revised IES package and supporting documents is available at http://www.decal.ga.gov/BftS/FormList.aspx?cat=CACFP.

Frequently Asked Questions

Q. What information do I issue to parents?
A. Institutions and facilities should issue the IES form, reduced income guidelines with the privacy and non-discrimination statement, appropriate household letter, and the Sharing Information with Medicaid/SCHIP letter to parents/guardians of children/adults participating in the CACFP.

Q. Can centers/day care homes require parents/guardians to complete the IES form as part of the enrollment package?
A. Centers/day care homes can request that parents/guardians complete the form as part of the enrollment process, but centers should not require parents/guardians to complete the form nor should they have policies/practices in place that negatively impacts the prospective/current participant’s enrollment if the parent declines or fails to complete or submit the form. This action would be in violation of the Program.

Q. Why is it necessary to issue the Sharing Information with Medicaid/SCHIP letter to parents?
A. Parents/guardians that do not wish to have their information shared with either Medicaid or SCHIP must complete the form and return to facility. Otherwise and when requested by Bright from the Start or the United States Department of Agriculture (USDA), parent/guardian information will be shared with Medicaid/SCHIP.

Q. Is it necessary to have three official’s signatures on the new IES form-especially when the center is an independent center with only one staff person managing the CACFP?
A. No. Only one signature is required for Independent centers with only one staff person responsible for managing the CACFP. However, institutions with more than one person managing the CACFP, and center and administrative sponsors are required to have a minimum of two signatures: determining official and confirming official.

Q. What is the purpose of having a determining and confirming official signature?
A. The confirming official will review the form and ensure accuracy and completeness. IES forms are considered current and valid until the last day of the month in which the form was dated on year earlier. The date to be used to make this determination is the date in which the sponsor or institution official signs the IES form to certify eligibility of the participant.

Q. How long is the IES form considered current and valid?
A. IES forms are considered current and valid until the last day of the month in which the form was dated one year previously. The date used to make this determination is the date in which the sponsor/ independent center official or parent/guardian signs the IES form. CACFP institutions and SFSP sponsors must decide which date they will use as the effective date and apply this date to all income eligibility forms submitted on behalf of all participants. CACFP institutions and SFSP sponsors are required to complete the Income Eligibility - Effective Date Option Form. In addition, institutions must indicate the options chosen in Section VIII. Recordkeeping (Item #2) of their Management Plan.

This means that sponsor and independent center officials should not request parent/guardians to complete IES forms at a specific frequency (e.g. start of each school year, every June, etc.). Request made by the sponsor or independent center official for IES form completion should be based solely on the expiration date of the IES forms.

Q. Do I send a report to Bright from the Start listing parent/guardians that want their information shared with Medicaid/SCHIP?
A. No. When instructed by USDA, Bright from the Start will request and collect data from institutions.

Q. Can this form be used for children in childcare facilities and adults in adult daycare facilities?
A. Yes.

Q. Can siblings be listed on one form?
A. Yes. Siblings from the same household can be listed on one form as long as there is space available.

Q. When do I verify parent/guardian income?
A. At the request of the United States Department of Agriculture (USDA), Bright from the Start, or any of its agents.

Q. Where can I get copies of the IES form and supporting documents?
A. Access Bright from the Start’s webpage at http://www.decal.ga.gov/BftS/FormList.aspx?cat=CACFP

Q. Can I still participate in the CACFP if parents do not complete the IES form or do not return the form to my center?
A. Yes. However, children that do not have IES forms on file must be placed in the “paid” category on the roster, which will effect monthly reimbursement. Centers that are using the IES form to capture annual enrollment information will be required to use an alternate enrollment form that captures at a minimum the name of the child, normal hours and days of care and meals the child usually receives while in attendance.

Q. What if the form is completed by the parent but is not signed and dated by the sponsor or independent official. Is the form valid?
A. The form would neither be current nor valid for free or reduced price meals since the signature and date of the sponsor or independent official is the certification of the eligibility of the participant.

Q. Are households required to report changes in circumstances?
A. No, Public Law 108-265 modified the requirements related to reporting changes in income during the period of eligibility covered by the application. Households are not required to report changes in circumstances, such as increase in income, a decrease in household size, or when the household is no longer certified eligible for benefits through Supplemental Nutrition Assistance Programs (SNAP) or Temporary Assistance for Needy Families (TANF).

Q. Are temporary approvals (45 days) still required when no income is reported?
A. No. Temporary approvals previously provided for short term assistance, such as when a household experienced a temporary income reduction or when no income was reported have been eliminated, are no longer required. Now, year-long eligibility includes households that report no income on their IES forms.

Q. Can parents list some but not all of the household income received?
A. No, the IES form requests all the household income including the frequency. By signing the IES form the parent/guardian certifies that all the information on the form is true and that all income is reported and that they understand that the center or day care home will receive Federal funds based on the information listed by the parent/guardian.

SHARING INFORMATION WITH MEDICAID/SCHIP

Dear Parent/Guardian:

If your children qualify for free or reduced price meals, they may also be able to get free or low cost health insurance through Medicaid or the State Children's Health Insurance Program (SCHIP). Children with health insurance are more likely to get regular health care and are less likely to become sick.

Because health insurance is so important to children's well-being, the law allows us to tell Medicaid and SCHIP that your children are eligible for free or reduced price meals, unless you tell us not to. Medicaid and SCHIP only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children in this health insurance program. Filling out the CACFP Meal Benefit Income Eligibility Forms does not automatically enroll your children in health insurance.

If you do not want us to share your information with Medicaid or SCHIP, fill out the form below and send it with your Income Eligibility Form to [address] by [date]. (Sending in this form will not change whether your children get free or reduced price meals.).

No! I DO NOT want information from my CACFP Meal Benefit Income Eligibility Form shared with Medicaid or the State Children's Health Insurance Program.

If you checked no, fill out the form below.

Child's Name *

Child's Name *

Child's Name *

Child's Name *

Guardian *

Today's Date:

Print Your Name *

Address *

For more information, you may call

at

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Baby Wipes	Band-aids	Neosporin or similar ointment	Bactine or similar first aid spray
Sunscreen	Insect Repellent	Non-Prescription ointment (such as A & D, Destin, Vaseline)	Baby Powder
Other (Please Specify)

Household size	Reduced Meal Income Limits
	Annually	Monthly	Twice A Month	Every Two Weeks	Weekly
1	22,459	1,872	936	864	432
2	30,451	2,538	1,269	1,172	586
3	38,443	3,204	1,602	1,479	740
4	46,435	3,870	1,935	1,786	893
5	54,427	4,536	2,268	2,094	1,047
6	62,419	5,202	2,601	2,401	1,201
7	70,411	5,868	2,934	2,709	1,355
8	78,403	6,534	3,267	3,016	1,508
For each additional family member add	+ 7,992	+ 666	+ 333	+ 308	+ 154