CACFP School-age Child in Care

You can enter information for up to five different children, six years and older (required September through May).

I HEREBY CERTIFY to the best of my knowledge that this information is true, correct, and in accordance with the terms of our existing agreement and that records are available to support this information. I understand that this information is being given in connection with the receipt of federal funds and that deliberate misrepresentation may subject me to prosecution under applicable state and federal criminal statutes.

Please complete all required fields.

My six-digit provider number

My name (first and last)

School-age child #1 name (first and last)

Present at  A.M. Snack  Lunch

Date(s) child was present on a normal school day

Reason  Sick  School closed  School delay  Half-day school  Other (please explain below)

Please explain

School-age child #2 name (first and last)

Present at  A.M. Snack  Lunch

Date(s) child was present on a normal school day

Reason  Sick  School closed  School delay  Half-day school  Other (please explain below)

Please explain

School-age child #3 name (first and last)

Present at  A.M. Snack  Lunch

Date(s) child was present on a normal school day

Reason  Sick  School closed  School delay  Half-day school  Other (please explain below)

Please explain

School-age child #4 name (first and last)

Present at  A.M. Snack  Lunch

Date(s) child was present on a normal school day

Reason  Sick  School closed  School delay  Half-day school  Other (please explain below)

Please explain

School-age child #5 name (first and last)

Present at  A.M. Snack  Lunch

Date(s) child was present on a normal school day

Reason  Sick  School closed  School delay  Half-day school  Other (please explain below)

Please explain

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