Child’s Name ______________________________ DOA __________________

CDI/CDC Enrollment File Requirements

(Attach to front cover of Child’s File)

SECTION I: Forms Required in All Files: Emergency Card & Release Form (2 required) (LIC 700 & 627) Emergency Card & Release Form - Addendum (CDI-LIC 700) Child’s Preadmission Health History-Parents Report (CDI-LIC 702) (2 pgs) Family and Social History (CDI/CDC 100) (3 pgs) Sunscreen and Care Product Utilization Consent (CDI/CDC 101) Notification of Parents Rights Receipt (CDI-LIC 995) Caregiver Background Check Process (CDI-LIC 995E) Notification of Personal Rights Receipt (CDI-LIC 613A) Racial-Ethnic Data Collection Letter (CNFDD 3201) (2 pgs) Letter to Parents Eligibility Scale Food Program CACFP (NSD 3104) (2pgs) Parent Handbook Receipt Form (signed/dated) Current CDI/CDC Registration Agreement (CDI/CDC)

SECTION II: Additional Forms Required for Non-School Age Children: Physician’s Report – Preadmission Health Evaluation (CDI-LIC 701) (2 pgs) CA School Immunization Record (“Blue Card”) (PM 286) Infant Needs, Services and Feeding Plan- Infant/Toddler Programs (CDI/CDC 200) (4 pgs) Toilet Training Plan - Infant/Toddler Programs (CDI/CDC 201)

SECTION III: Forms Required IF APPLICABLE: Exemption from Medical Assessment/Immunizations (No pre-printed form; parent, guardian or physician to provide a

written statement for exemption)

Document of Unusual Behavior, Signs of Illness or Special Needs (CDI/CDC 300) M.D. Statement to Request Special Meals/Accommodations (CNP 925) (2 pgs) Medication Administration Release (CDI-LIC 9221) Centrally Stored Prescription Medication and Destruction Record (CDI-LIC 622) (2 pgs) Unusual Incident/Injury Report (CDI-LIC 624) (2 pgs) Asthma Metered Dose Inhaler & Nebulizer Care Consent/Verification Form (CDI-LIC 9166) Gastrostomy - Tube Care/Physicians Checklist (CDI-LIC 701A) (2 pgs) Licensing Report Receipt (CDI-LIC 9224) Verification of Authorized Family Representative (CDI/CDC 301) Blank Contact/Action Log Form (CDI/CDC 302) Parent/Guardian Release for Allergy Information (CDI/CDC 303) Anaphylaxis Emergency Plan (CDI/CDC 304)

SECTION IV: CACFP Forms Required IF APPLICABLE: Meal Benefit Form w/instructions (NSD 3101) (3 pgs) USDA Infant Meal Pattern (NSD 07/03) CACFP Meal Pattern for Older Children (NSD 08/2006) Parent Declining Provider Formula/Food (NSD 09/02) (2 pgs)

September 2014

Dear Parents:

Welcome to Child Development Centers. We are pleased that you have chosen our program for your child. It is our goal to be your partner in the care and nurturing, academic success and recreational experience your child will have at our Center. We see respectful parent/family relationships as essential in our commitment to achieving excellence in our programs. Our dedicated and trustworthy teachers will ensure that your child is safe and has fun in a comfortable, home-like setting, where each child can be his or her best self.

Enclosed you will find the Enrollment Packet that contains information required by the California Department of Education and Community Care Licensing, as well as information we need about your family and child in order to be your full partner. Our centers are licensed by the California Department of Social Services Community Care Licensing Division, the state-wide agency responsible for health and safety reviews of childcare centers. In addition, all of our centers are seeking National Accreditation Standards of Excellence.

Our programs are customized, unique and specific to the needs of each local community and the families within them. Whether an infant, toddler, preschooler or in elementary school, our programs will support your child’s growth and development, provide a rich environment for learning, provide age-appropriate activities based on your child’s individual interests and surround your child in a safe and healthy environment.

Most importantly, we want your child to develop friendships, trust and interact with adults, develop leadership skills, follow their interests and enjoy their time with us. We look forward to developing a strong relationship with your child and your family.

Please feel free to visit the center at any time. Consider us to be like part of your family.

Sincerely,

Carol Anderson President

Parent Instruction 8-03-09 1

Parent/Guardian Instructions for Completing Enrollment Packet

We hope this guide will assist you in completing the Enrollment Application Packet.

1. “Emergency Card and Release Form” (LIC 700 & LIC 627) - Please fill out two(2) for each child. This card provides instruction to Center Staff on what steps tofollow in the event of an emergency.

2. “Emergency Card and Release Form – Addendum” (CDI-LIC 700) – Please fillthis out for any Family Representative you authorize to take your child from theCenter. A Family Representative will need to furnish photo identification toCenter Staff in order to be added as authorized to take your child from the Center.(If someone you want to be authorized to pick up your child from the Center doesNOT have a form of photo identification, please ask Center Staff for formCDI/CDC 301.)

3. “Child’s Preadmission Health History – Parent’s Report” (CDI-LIC 702) – Pleasefill out this form completely. If your child has any allergies, is taking prescribedor over the counter medicine, or has any special needs (food, special devices,medical) please ask Center Staff for the appropriate form(s) to provide completeinformation on any special needs. (For Infant/Toddler & Pre-School Children,please see additional forms in the following section.)

4. “Family and Social History” (CDI/CDC 100) – Please fill this out completely tohelp Center Staff fully understand your child’s environment, social needs andfamily setting to help them feel comfortable and at home while at the Center.

5. “Care Product Utilization Release” (CDI/CDC 101) – Please indicate any CareProducts that should not be used on your child and provide alternate instructionfor preventative care.

6. “Notification of Parent’s Right” (CDI-LIC 995) – This document is to inform youof your Rights while your child is enrolled at the Center. Please read thiscarefully and sign and date the bottom “Acknowledgement” portion of the form.

7. “Personal Rights” (LIC 613A) - This document is to inform you of all the rightsaccorded to your child while enrolled at the Center. Please read this carefully andsign and date the bottom “Acknowledgement” portion of the form.

8. “Letter to Parents to Collect Racial-Ethnic Data” (CNFDD 3201) – This form willassist the Center in providing healthy nutrition to the children as part of aFederally sponsored food program, however, it is NOT mandatory. If you declineto provide this information, it will NOT affect your applications or your child’sparticipation in this food program.

9. “Letter to Parents (Child Care Center – Non-Pricing Program)” (NSD3104) –Please read this communication to determine if your child may be eligible for thisProgram. The program helps the Center defray the cost of nutritious snacks andmeals. After reviewing this, please check the appropriate box at the bottom so theCenter Staff can furnish additional information if applicable.

10. “Parent Handbook Receipt” – You will be given a Child Development Centers -Parent Handbook to read and review describing important information you should

Parent Instruction 8-03-09 2

know about our Centers and Programs. Please be sure to sign and date the last page of this handbook confirming you received it.

Forms Specific to Infant/Toddler & Pre-School Children:

1. “Physician’s Report – Child Care Centers” (CDI-LIC 701) - Please have this form completed by yourself and your child’s physician. If your child has any allergies, is taking prescribed or over the counter medicine, or has any special needs (food, special devices, medical) please ask Center Staff for the appropriate form(s) to provide complete information on any special needs.

2. “Infant Needs, Services and Feeding Plan” (CDI/CDC 200) – Please read and complete this form to help our Center Staff understand and fill your child’s nutritional needs, special service needs, feeding methods and to authorize expanding their dietary intake as they grow. Be sure to sign and date this form.

3. “Toilet Training Plan” (CDI/CDC 201) – If your child is ready for or in the process of Toilet Training, please read this form and discuss a Plan with the Center Staff to help support this challenge.

We hope this guide was helpful to you in filling out the information required for your Child to participate at our Center.

CDI/CDC Emergency Card and Release Form -- Addendum

List additional Family Representative(s) (who possess photo identification) who are authorized to take child from the Facility. Attach to the child’s Emergency Card and Release Form.

Name of Child _____________________________________

1) __________________________________________ ____________________________ (_______) _____________________ Print Name of Authorized Family Representative Relationship Day Phone

___________________________________ ____________________________ Signature of Authorized Family Representative Date 2) __________________________________________ ____________________________ (_______) _____________________ Print Name of Authorized Family Representative Relationship Day Phone

___________________________________ ____________________________ Signature of Authorized Family Representative Date 3) __________________________________________ ____________________________ (_______) _____________________ Print Name of Authorized Family Representative Relationship Day Phone ___________________________________ ____________________________ Signature of Authorized Family Representative Date ___________________________________ _______________________ Parent/Guardian Signature Date CDI-LIC 700 (8/08)

CDI/CDC

Emergency Card and Release Form -- Addendum List additional Family Representative(s) (who possess photo identification) who are authorized to take child from the Facility. Attach to the child’s Emergency Card and Release Form.

Name of Child _____________________________________

1) __________________________________________ ____________________________ (_______) _____________________ Print Name of Authorized Family Representative Relationship Day Phone

___________________________________ ____________________________ Signature of Authorized Family Representative Date 2) __________________________________________ ____________________________ (_______) _____________________ Print Name of Authorized Family Representative Relationship Day Phone

___________________________________ ____________________________ Signature of Authorized Family Representative Date 3) __________________________________________ ____________________________ (_______) _____________________ Print Name of Authorized Family Representative Relationship Day Phone ___________________________________ ____________________________ Signature of Authorized Family Representative Date ___________________________________________ _______________________ Parent/Guardian Signature Date CDI-LIC 700 (8/08)

 

CDI-LIC 702 Page 1 of 2

CDI/CDC Child’s Preadmission Health History – Parent’s Report

CHILD’S NAME SEX

□ M □ F

BIRTH DATE

FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME

DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN

HOME WITH CHILD? □ Yes □ No MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME

DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE

IN HOME WITH CHILD? □ Yes □ No DOES CHILD HAVE A PRIMARY CARE PHYSICIAN?

□ Yes □ No

DATE OF LAST PHYSICAL/MEDICAL EXAMINATION

DEVELOPMENTAL HISTORY (please complete for infants and preschool age children only) WALKED AT:

MONTHS BEGAN TALKING AT:

MONTHS TOILET TRAINING BEGAN AT:

MONTHS

DAILY ROUTINES WHAT TIME DOES CHILD GO TO BED?

WHAT TIME DOES CHILD GET UP?

DOES CHILD SLEEP WELL?

□ Yes □ No

DOES CHILD SLEEP DURING THE DAY?□ Yes □ No

IF YES, WHAT TIME? HOW LONG?

DIET PATTERN: What does child usually eat for these meals? Time of Meals BREAKFAST:

LUNCH:

DINNER

DOES YOUR CHILD HAVE ANY DIFFICULTY EATING FOOD? □ Yes □ No

IS CHILD TOILET TRAINED? □ Yes □ No IF YES, AT WHAT STAGE?

WHAT WORD DOES YOUR CHILD USE FOR “BOWEL MOVEMENT”?

ARE BOWEL MOVEMENTS REGULAR? □ Yes □ No WHAT IS THE USUAL TIME?

WHAT WORD DOES YOUR CHILD USE FOR URINATION?

CURRENT MEDICAL CONDITION: Check all conditions that currently apply to your child and the date of diagnosis

□ ADD/ADHD

□ ASTHMA (Asthma Action Plan required)

□ BLOOD DISORDERS Name of condition: ________________________

□ DIABETES

□ DEVELOPMENTAL DELAY Type:___________________

DATES □ NON-FOOD ALLERGY List allergy below: ___________________

□ HEART CONDITION Name of condition: _____________________

□ SEIZURES Date of last episode:

DATES □ HEARING IMPAIRMENT

□ VISION IMPAIRMENT

□ ECZEMA

□ GENETIC CONDITION:

____________________

□ OTHER:

DATES

5/11 –C EP) 2-childs preadmission health history-parents report.adm

 

CDI-LIC 702 Page 2 of 2

 

PARENT’S SIGNATURE DATE

DOES YOUR CHILD HAVE FOOD ALLERGIES? □Yes □ No (if Yes, form CNP 923 is required) If Yes, list foods to avoid:

IS YOUR CHILD’S ALLERGY LIFE-THREATENING? □Yes □ No

IS AN EPIPEN REQUIRED IN THE CASE OF AN ALLERGIC REACTION? □Yes □ No (if Yes, the Anaphylaxis Emergency Action Plan form and Consent to Release Allergy Information form are both required)

WHAT IS YOUR OVERALL EVALUATION OF CHILD’S HEALTH?

DOES CHILD HAVE HEALTH INSURANCE? □ Yes □ No

IS CHILD CURRENTLY UNDER A PHYSICIAN’S CARE? □ Yes □ No

IF YES, NAME OF PHYSICIAN:

DOES CHILD TAKE PRESCRIBED MEDICATION(S)? □ Yes □ No NAME OF MEDICATION(S):

DOES MEDICATION NEED TO BE PROVIDED DURING CENTER HOURS? □ Yes □ No (If Yes, the Medication Administration Release form is required. If the medication is an asthma inhaler or nebulizer, the Asthma Metered Dose Inhaler/Nebulizer Care Consent/Verification form is also required.)

LIST ALL SIDE EFFECTS OF MEDICATION (if any):

DOES CHILD USE ANY SPECIAL DEVICES AT HOME? □ Yes □ No NAME OF DEVICE:____________________________

IF YES, WILL CHILD NEED DEVICE AT THE CENTER? □ Yes □ No DESCRIBE CHILD’S PERSONALITY: DESCRIBE CHILD’S INTERACTIONS WITH SIBLINGS AND OTHER CHILDREN:

HAS CHILD HAD GROUP PLAY EXPERIENCES? □ Yes □ No

DOES CHILD HAVE ANY SPECIAL PROBLEMS, NEEDS OR FEARS? □ Yes □ No IF YES, PLEASE EXPLAIN: WHAT IS THE PLAN FOR CARE WHEN CHILD BECOMES ILL AT THE CENTER?

IS THERE ANYTHING ELSE WE NEED TO KNOW ABOUT YOUR CHILD? □ Yes □ No IF YES, PLEASE EXPLAIN: PURPOSE OF REQUESTING CHILDCARE PLACEMENT AT CDI/CDC: DESCRIBE ANY ACTIVITIES YOUR CHILD SHOULD BE EXEMPTED FROM DUE TO HEALTH REASONS:

CDI/CDC 100 (06/09) 1

CDI/CDC Family and Social History

Child’s Name__________________________ Nickname ___________________ Parent/Guardian_________________________________________________________ 1.) How did you hear about our Program?_____________________________________ 2.) Please describe your family structure (include information about who the child lives with or persons who regularly care for the child both in and out of the home and state the relationship to the child). _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Other household members: Name Relationship Age or Date of Birth _______________________________________________________________________________________________________________________________________________________________________________________ 3.) Language(s) spoken in the home: __________________________________________ 4.) Family hobbies and interests: _____________________________________________ 5.) Family pets (type and name): _____________________________________________ 6.) Are there any home/family situations you would like us to be aware of? YES

NO (If YES, please explain below.) _______________________________________________________________________________________________________________________________________________________________________________________ 7.) Has the child been cared for by anyone other than parents? YES NO (If YES, please explain below.) By Whom How Long When _______________________________________________________________________________________________________________________________________________________________________________________

CDI/CDC 100 (06/09) 2

8.) Other group care/school/day camp experience? YES NO (If YES, explain below.) Where How Long When _______________________________________________________________________________________________________________________________________________________________________________________ 9.) What experiences would you like you child to have in the center/camp? _______________________________________________________________________________________________________________________________________________________________________________________ 10.) Child’s favorite activity/sport: ___________________________________________ 11.) What methods are used to change undesirable behaviors at home? __________________________________________________________________________________________________________________________ 12.) Do you have any concerns about your child’s development? YES NO (If YES, explain below.) _______________________________________________________________________________________________________________________________________________________________________________________ Because we want to respect the cultures and traditions that you bring to our program and we desire to be inclusive in center-wide celebrations, please take time to fill out the following questions. What would you like us to know about your family celebrations/traditions? _______________________________________________________________________________________________________________________________________________________________________________________ Are there special days that you would like us to be aware of? YES NO (If YES, please explain below.) _______________________________________________________________________________________________________________________________________________________________________________________

CDI/CDC 100 (06/09) 3

Is there anything about your culture or family you might be worried we do not understand? YES NO (If YES, please explain below.) _______________________________________________________________________________________________________________________________________________________________________________________ Is there anything in the celebrations of others which you would not want your child to participate in? YES NO (If YES, please explain below.) _______________________________________________________________________________________________________________________________________________________________________________________ What kinds of things can we do to strengthen our center community and bring us together to promote friendship? _______________________________________________________________________________________________________________________________________________________________________________________ Would you have time to volunteer at our Center? YES NO (If YES, please indicate what you might be interested in doing by checking an item(s) below.)

Read or share a favorite story in your native language. Share a favorite family recipe. Donate articles of clothing or other artifacts for our “dress-up” corner that you no

longer use. Other activities you might share:

____________________________________________ Please indicate any other important information you would like to share with us about your child. _______________________________________________________________________________________________________________________________________________________________________________________ ______________________________________ _______________ Parent/Guardian Signature Date

 

2/11-C EP) Sunscreen & Care Product Utilization Consent.adm                          CDI/CDC 101 (2011)   

CDI/CDC

Sunscreen and Care Product Utilization Consent Name of Child: _________________________________ Date: ____/____/____

Children 6 Months of Age and Older As the parent or guardian of the above child, I recognize that too much sunlight may increase my child’s risk of getting skin cancer. Therefore, I give my permission for CDI/CDC staff to apply a sunscreen product of SPF 30 or higher to my child (unless otherwise noted below) when he or she will be playing outside, especially during the months of April through September and between the daily times of 10 a.m. to 4 p.m. A brand of sunscreen is purchased in bulk and provided by CDI/CDC for use on children. If my child needs a different brand of sunscreen, I am responsible for providing the center with a substitute. I understand that sunscreen may be applied to exposed skin, including but not limited to the face, tops of ears, nose and bare shoulders, arms and legs (inquire with the Site Supervisor for the current brand of sunscreen used). If I do not want sunscreen applied to my child, or if I prefer to provide a different sunscreen than the center provides, I have indicated this by initialing the appropriate statement below. _____ I do not want sunscreen applied to my child’s skin.

_____ I will provide a brand of sunscreen that is different from what the center uses. (The sunscreen I provide will be stored at the center) Brand of sunscreen: __________________________________________________.

Infant & Toddler Care Only I give my consent for CDI/CDC staff to use the over the counter products listed below during the care of my infant/toddler. I understand that CDI/CDC reserves the right to substitute the following brand name products with a similar product of a different name. If I DO NOT want a product listed below used on my child, I will write my initials next to the product name. _____ Vaseline® _____ Desitin ® (Cream for Diaper Rash) I understand this service is an accommodation for me and I will not hold the staff, Site Supervisor, or CDI/CDC liable for the proper administration of the items listed on this page or for any adverse effects of their use. ______________________________________ __________________ Parent/Guardian Signature Date

CDI-LIC 995 (9/08)

CDI/CDC Notification of Parent’s Rights

PARENT’S RIGHTS As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file

kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against

the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or

retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the

child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office.

Licensing Office Name: ______________________________________________ Licensing Office Address: ____________________________________________ Licensing Office Telephone #: _________________________________________

7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.

8. Receive, from the licensee, the Caregiver Background Check Process form. NOTE: California State law provides that the licensee may deny access to the child care center to a parent / authorized representative if the behavior of the parent/authorized representative poses a risk to children in care.

For the Department of Justice “Registered Sex Offender” data base, go to www.meganslaw.gov

Detach here

ACKNOWLEDGEMENT OF NOTIFICATION OF PARENT’S RIGHTS (Parent/Authorized Representative Signature Required)

I, the parent/authorized representative of______________________________________, have received a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and the CAREGIVER BACKGROUND CHECK PROCESS form from the licensee. _____________________________________ Name of Child Care Center __________________________________________________ __________________ Signature (Parent/Authorized Representative) Date NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given to parent/authorized representative.

For Department of Justice “Registered Sex Offender” data base, go to www.meganslaw.gov

CDI-LIC 995E (8/02)

CDI/CDC

Caregiver Background Check Process The California Department of Social Services works to protect the safety of children in child care by licensing child care centers and family child care homes. Our highest priority is to be sure that children are in safe and healthy child care settings. California law requires a background check for any adult who owns, lives in, or works in a licensed child care home or center. Each of these adults must submit fingerprints so that a background check can be done to see if they have any history of crime. If we find that a person has been convicted of a crime other than a minor traffic violation, he/she cannot work or live in the licensed child care home or center unless approved by the Department. This approval is called an exemption. A person convicted of a crime such as murder, rape, torture, kidnapping, crimes of sexual violence or molestation against children cannot by law be given an exemption that would allow them to own, live in or work in a licensed child care home or center. If the crime was a felony or a serious misdemeanor, the person must leave the facility while the request is being reviewed. If the crime is less serious, he/she may be allowed to remain in the licensed child care home or center while the exemption request is being reviewed. How the Exemption Request is Reviewed We request information from police departments, the FBI and the courts about the person’s record. We consider the type of crime, how many crimes there were, how long ago the crime happened and whether the person has been honest in what they told us.

The person who needs the exemption must provide information about:

• The crime

• What they have done to change their life and obey the law

• Whether they are working, going to school, or receiving training

• Whether they have successfully completed a counseling or rehabilitation program

The person also gives us reference letters from people who aren’t related to them who know about their history and their life now. We look at all these things very carefully in making our decision on exemptions. By law this information cannot be shared with the public. How to Obtain More Information As a parent or authorized representative of a child in licensed child care, you have the right to ask the licensed child care home or center whether anyone working or living there has an exemption. If you request this information, and there is a person with an exemption, the child care home or center must tell you the person’s name and how he or she is involved with the home or center and give you the name, address, and telephone number of the local licensing office. You may also get the person’s name by contacting the local licensing office. You may find the address and phone number at http://ccld.ca.gov/docs/maps/state.htm

IMPORTANT INFORMATION FOR PARENTS

CDI-LIC 613A (8/08)

CDI/CDC

Personal Rights

Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers. (a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights

which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and

equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation,

intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child.

(6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in

advance by the licensing agency. The representative/Parent/Guardian has the right to be informed of the appropriate licensing agency to contact regarding complaints, which is: NAME ADDRESS CITY

ZIP CODE AREA CODE / TELEPHONE NUMBER

Detach Here

To: Parent/Guardian/Child or Authorized Representative: Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgement: ACKNOWLEDGEMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to: PRINT NAME OF FACILITY PRINT THE ADDRESS OF THE FACILITY

PRINT THE NAME OF THE CHILD SIGNATURE OF REPRESENTATIVE / PARENT / GUARDIAN TITLE OF THE REPRESENTATIVE / PARENT / GUARDIAN DATE

Place in Child’s File

CDI/CDC

Letter to Parents to Collect Racial-Ethnic Data

DATE

Dear Parent/Guardian: The California Department of Education, Child and Adult Care Food Program (CACFP) is required to administer the Provisions of Title VI of the Civil Rights Act of 1964. The Act requires collection of racial-ethnic information about each person participating in a federally funded program. Although you are not required to provide this information, it will assist us in complying with this federal law. The information collected is for statistical reporting requirements only and will be treated as confidential. If you decline to provide this information, it will not affect your application or your children’s participation in the CACFP.

Please return this form to:

NAME OF PERSON AUTHORIZED TO COLLECT THIS DATA

by

DATE

Sincerely,

NAME OF SITE SUPERVISOR NAME OF SPONSOR

NAME OF ENROLLED CHILD

Please mark the racial-ethnic category your child(ren) identifies with:

American Indian Black or Native Hawaiian or or Alaska Native Asian African American other Pacific Islander White

ETHNIC IDENTITY Check ( ) box if this participant is Hispanic or Latino

7/12 –EP) 8-racial-ethnic data collection letter (2 pgs)

CNFDD 3201 (3/07)

7/12 –EP) 8-racial-ethnic data collection letter (2 pgs)

CDI/CDC Description of Racial and Ethnic Categories

The federal government has established the following five racial categories and one ethnic category: RACE: American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam. Black or African American – A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American." Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. ETHNICITY: Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish origin" can be used in addition to "Hispanic or Latino." Not Hispanic or Latino

NSD 3104 (06/14)1

CDI/CDCLETTER TO PARENTS

(Child Care Center – Non-Pricing Program)

Dear Parent/Guardian:

All CDI/CDC child care centers participate in the Child and Adult Care Food Program (CACFP) offered by theUnited States Department of Agriculture (USDA) and serve meals at no separate charge to all enrolled children. Thereimbursement received from the CACFP helps with our food costs, and enables us to keep our fees for care as lowas possible.

Please help us comply with the requirements of the U.S. Department of Agriculture's (USDA) Child and Adult CareFood Program (CACFP). All children enrolled in our centers receive their meals at no separate charge, but thedetermination of eligibility category affects the amount of funding received by our centers. This information isnecessary to receive the reimbursement for the meals we serve to children in our program. . If your household'sincome is equal to or less than the amounts indicated for your household's size on the Income Eligibility Chartbelow, the center receives a higher level of Federal reimbursement for meals served to your child(ren).

Effective from July 1, 2014 through June 30, 2015HOUSEHOLD SIZE* MONTHLY INCOME

1 $ 1266 – 18002 $ 1706 – 24263 $2145 – 30514 $ 2585 – 36775 $ 3025 – 43036 $ 3465 – 49297 $ 3905 – 55558 $ 4345 – 6181

For each additional family member, add: + $ 626*A household of one means a child who is his or her sole support. Foster children are one-member households onlyif the welfare or the placement agency maintains legal responsibility for the child.

USDA defines household as a group of related or unrelated individuals who are not residents of an institution orboarding house, but who are living as one economic unit sharing housing and all significant income and expenses.The income you report must be the total gross income received last month, listed by source for each householdmember. If last month's income does not accurately reflect your circumstances, you may provide a projection ofyour monthly income. If no significant change has occurred, you may use last year's income as a basis to make thisprojection

PLEASE CHECK THE APPROPRIATE BOX: (Refer to the Income Eligibility Chart listed above)

I believe I qualify. My household currently receives benefits under the Food Stamp Program; the CaliforniaWork Opportunity and Responsibility for Kids (CalWORKs); the Kinship Guardian Assistance Payment (Kin-GAP); or the Food Distribution Program on Indian Reservations (FDPIR).(Please request and complete the Meal Benefit Form from our Representative.)

I believe I qualify based on my household size and the total monthly income of my household.(Please request and complete the Meal Benefit Form from our Representative.)

I am enrolling a foster child(ren) and qualify.(Please request and complete the Meal Benefit Form from our Representative.)

I believe I DO NOT qualify based on my household size and the total monthly income of my household.

NSD 3104 (06/14)2

Once properly approved for free or reduced-price benefits, whether through income or proof of benefits as supportedby a current Food Stamp, CalWORKs, Kin-GAP, or FDPIR case number, your child(ren) will remain eligible forthose benefits for 12 months. When completing the Meal Benefit form remember to include the names of allhousehold members, their income by source and the social security number of the signing adult or check the box“Check here if no Social Security Number”. If English is not your first language you have the right to ask for writtenor oral translation of these materials free of charge in your native language.

Confidentiality of Information on the Meal Benefit Form:

We will use the information on the form to decide the level of reimbursement our centers are eligible to receive. Wewill place the Meal Benefit Form in our food program files and keep the information confidential. Only upon yourrequest, will we share the information on your form with officials of other child nutrition, health, and educationprograms so they can use it to determine benefits for those programs.

Nondiscrimination Statement:

This explains what to do if you believe you have been treated unfairly. In accordance with Federal law and U.S.Department of Agriculture policy, this agency is prohibited from discriminating on the basis of race, color, nationalorigin, sex, age, or disability.

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights,Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington DC 20250-9410, or call 202-720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

Thank you for your cooperation. If you have any questions or need assistance in filling out the Meal Benefit Form,please contact:

CENTER REPRESENTATIVE TELEPHONE NUMBER

Sincerely,

Agency Representative Signature Date