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Home My WebLink About840922.tiff fe ` ' EinoRgnDum IR ' , , O 9 To Norman Carlson, Chairman Date September 18, 1984 Board of County Commissioners 1f /// / COLORADO From Walter J. Speckman, Executive Director, Human Resources C1,/ // Subject: Head Start Agreement with the Child Care Food Program Enclosed for Board approval is the Head Start Agreement with the U.S. Depart- ment of Agriculture, Food and Nutrition Service, Child Care Food Program. The Agreement provides for reimbursement costs of meals (breakfasts, snacks, and lunches) provided to the Head Start Program. This Agreement will begin October 1, 1984 and end September 30, 1985. If you have any questions, please feel free to telephone me at 353-0540. F.4.O,. ;fpf d • _ FORM APPROVED OMB NO.6604-0495 U.S.DEPARTMENT OF AGRICULTURE FOR FNS USE ONLY FOOD AND NUTRITION SERVICE AGREEMENT NUMBER AGREEMENT f1a_FS ( ;Ir..() (CHILD CARE FOOD PROGRAM) '"f � C CTV P1: nF C�tvvl CgTfrppG NEA0 STGFT—CCFP tipP INSTRUCTIONS: The Institution should complete Sections A and Bin dupli- Pr, R f Y I ?n 5 cate, sign both copies and return to FNS Regional Office.The Regional Office (.:P HI.t FY r'!' F r•!. z , will complete Sections C and D, sign both copies and return one copy to the Institution. The Institution MUST RECEIVE A COPY OF THE CHILD CARE FOOD PROGRAM REGULATIONS. SECTION A CHILD CARE FOOD PROGRAM is approved to operate In order to carry out the purpose of Section 17 of the National from 10/01/84 to 09/30/85 School Lunch Act, as amended, and the Regulations governing the Child Care Food Program issued thereunder (7 CFR Part 226) the United States Department of Agriculture (hereinafter referred to as the "Department") and the Institution, whose name and THE DEPARTMENT AND THE INSTITUTION MUTUALLY address appear above,agree as follows: AGREE: ' THE INSTITUTION: To comply with and meet all responsibilities and requirements set forth in 7 CFR Part 226, Child Care Food Program Regulations. Represents and warrants that it will accept final administrative (Copy(ies)attached) and financial responsibility for total Child Care Food Program operations at all homes, centers, or proprietary Title XX centers That the Institution will be reimbursed under the following listed in Section C. methods: Understands and agrees that any publications by the Institution — For child care centers or outside-school-hours care centers, may be freely copied by the Department or by other Institutions according to the Institution's under the Child Care Food Program. ®Claiming Percentages,or Certifies as to the number of private for-profit child care centers under its auspices that received amounts granted to the State under ❑ Actual count of meals served by eligibility category. Title XX of the Social Security Act for at least 25 percent of each center's enrolled children during the month preceding application — For sponsoring organizations of day care homes, according to to the Program; and shall continue to certify and provide such the payment rates for administrative costs. information in each succeeding month. The Institution shall not claim reimbursement for meals served in any for-profit center for — For day care homes, according to the full food service payment any month during which the center :receives such compensation for rates. However, sponsoring organizations electing to receive less than 25 percent of its enrolled children. If the Institution is a commodities for family day care homes will-b - reimbursed at for-profit sponsoring organization, the Institution also certifies that the lower rates for lunches and suppers rather than at the full all centers under this Agreement have the same legal identity as the rates that include the value of commodities. Institution. 4 No monies or other benefits may be paid out under this Program unless this Agreement is completed and filed as required by existing Regulations(7 CFR Part 226) SECTION B Fill in the name and address of Centers and Homes for the Child Care Food Program. (Attach additional sheets if necessary.) TYPE OF CENTER OR NOME HOURS AND TYPE OF MEALS SERVED (Indicate "C"if Child Note No more than 3 meals per day Cart Center, "O"if per child shall be claimed. CHILD CARE FOOD PROGRAM OutsideSchool•Hours (Name and address of center or home). Care Center, "P"if Proprietary Title XX .BREAK- AM PM. Center, or "If"if FAST SNACK LUNCH SNACK SUPPER Day Care Home bl (D) (c) (d) (e) If) Igl 1. Greeley Head Start Center C 9:30 11:30 2:00 P.O. Box 1805 520 13th Ave. Greeley, CO 80632 Phone: (303) 356-0600 2. *Frederick Head Start Center C 8:30 11:30 2:00 St. Teresa's Church Frederick, CO 80530 Phone: (303) 833-9997 3. *Johnstown Head Start Center C 8:30 11:30 2:00 Letford Elementary School West Charlotte Street, Circle Drive Johnstown, CO 80534 Phone: (303) 587-2888 4. Pierce Head Start Center C 9:00 11:45 2:00 United Methodist Church 429 3rd Street Pierce, CO 80650 Phone: (303) 834-1264 *Vended Food r SECTION C (For FNS Regional Office U:el THE INSTITUTION AND THE DEPARTMENT MUTUALLY AGREE THAT THE INSTITUTION WILL RECEIVE FOR ITS CHILD CARE CENTERS AND OUTSIDE-SCHOOL-HOURS CARE CENTERS AND PROPRIETARY TITLE XX CENTERS. n DONATED COMMODITIES, OR fl CASH-IN-LIEU-OF-COMMODITIES SECTION D -- ANNUAL ADMINISTRATIVE BUDGET* 'THIS SECTION IS REQUIRED FOR ORGANIZATIONS WHICH SPONSOR DAY CARE HOMES. IT IS OPTIONAL FOR SPONSOR- ING ORGANIZATIONS OF CENTERS. ITEM APPROVED AMOUNT A. ADMINISTRATIVE LABOR $ -0- B. OFFICE SUPPLIES -0- C. POSTAGE -0- D. TRANSPORTATION FOR FACILITY MONITORING —0— E. MILEAGE ALLOWANCE FOR FACILITY MONITORING —0— CCFP's SHARE OF; F. TELEPHONE -0- G. OFFICE RENTAL AND MAINTENANCE -0-- H. UTILITIES FOR OFFICE AREA —0— I. OTHER (Specify) —0— J. TOTAL APPROVED ADMINISTRATIVE BUDGET $ —0— FORM FNS-344 (7-83 Previous editions obsolete. Page 3 NONDISCRIMINATION CLAUSE THE INSTITUTION: IIEREBY AGREES THAT it will comply with Title VI of the Civil lease, or furnishing of services to the recipient,or any improvements Rights Act of 1964 (P.L. 88-352) and all requirements imposed by made with Federal financial assistance extended to the applicant by the Regulations of the Department of Agriculture (7 CFR Part 15), the Department. This includes any Federal agreement,arrangement. Department of Justice (28 CFR Parts 42 & 50), and FNS directives or other contract which has as one of its purpoaes the provision of or regulations issued pursuant to that Act and the Regulations, to assistance such as food,food stamps,cash assistance for the purchase the effect that, no person in the United States shall,on the grounds of food, and any other financial assistance extended in reliance on o f age,sex,handicap,color,race,or national origin, be excluded from the representations and agreements made in this assurance. participation in,or be denied the benefits of,or be otherwise subject to discrimination under any program or activity for which the BY ACCEPTING THIS ASSURANCE, the applicant agrees to com- applicant received Federal financial assistance from the Department; pile data, maintain records and submit reports as required,to permit and HEREBY GIVES ASSURANCE THAT it will immediately take effective enforcement of Title VI and permit authorized USDA any measures necessary to effectuate this agreement. personnel during normal working hours to review such records, books and accounts as needed to ascertain compliance with Title VI. THIS ASSURANCE IS given in consideration of and for the purpose If there are any violations of this assurance, the Department of of obtaining any wad all Federal financial assistance,grants and loans Agriculture, Food and Nutrition Service, shall have the right to seek of Federal funds, reimbursable expenditures, grant or donation of judicial enforcement of this assurance. Federal property and interest in property, the detail of Federal personnel, the sale and lease of, and the permission to use, Federal This assurance is binding on the applicant,its successors,transferees, property or interest in such property or the furnishing of services and assignees as long as it receives assistance or retains possession of without consideration or at a nominal consideration, or at a con- any assistance from the Department. The person or persons whose sideration which is reduced for the purpose of assisting the recipient, signatures appear below are authorized to sign this assurance on the or in recognition of the public interest to he served by such sale, behalf of the applicant. • CERTIFICATION STATEMENT I HEREBY CERTIFY that all of the above information is true and correct.I understand that this information is being given in connection with the receipt of Federal funds; that. Department Officials may, for cause, verify information; and that deliberate misrepresentation will subject me to prosecution under applicable State and Federal criminal statutes. SIGNATURE ON BEHALF OF INSTITUTION BY UNITED STATES DEPARTMENT OF AGRICULTURE AUTHORIZED RR RESENTATIVE FOOD AND NUTRITION SERVICE REGIONAL OFFICE SIGNATURE SIGNATURE Norman Carlson, Chairman NAME: AME: (Print or Type) (Print or Type) Board of County Commissioners_ATE: 9/12/84 TIT, E r _ TITLE: __ _ ... _ _�_ Pare 4 FORM APPROVED OMB NO. 0584-0055 U.S. DEPARTMEN AGRICULTURE GREEMENT NUMBER FOOD AND NU' )TION SERVICE APPLICATION FOP PARTICIPATION & MANAGEMENT PLAN FOR SPONSORING ORGANIZATIONS IN THE CHILD CARE FOOD PROGRAM (CCFP) 08-65103 • INSTRUCTIONS: Complete in duplicate, Submit original,continuation sheets if needed, and required attachments,together with original Form FNS-341 'Application for Participation for Child Care Center)and attachments thereto for each nonresidential child care center and original Form FNS-432 'Application for Participation for Day Care Homes (CCFP))and attachments for each day care home under your administration. 1. NAME AND MAILING ADDRESS OF SPONSORING ORGANIZATION 2A. NAME AND TITLE OF ADMINISTRATOR (Authorized sponsoring (Include County) organization representative who will sign the Agreement, Form FNS-344) Norman Carlson, Chairman Weld County Division Board of County Commissioners of Human Resources 2B. NAME AND TITLE OF CCFP REPRESENTATIVE (Individual who P. 0. BOX 1805 can be contacted for Programmatic Information) Greeley, CO 80632 Juanita Santana, Director TELEPHONE NUMBER: AC (303) 353-0540 Dixie Hanson, Health Coordinator 4A. DOES ORGANIZATION PARTICIPATE IN THE HEADSTART 3. IS THIS A PRIVATE ORGANIZATION?(Private means non- PROGRAM? governmental) Ei NO ❑YES(If"yes,"attach a copy of the letter from IRS ®YES ❑ NO documenting tax-exempt status, or copy of application to IRS and cover letter which indicates that an application has been filed with IRS or documentation that center participates in another Federal program requiring non-profit status. DOES NOT APPLY TO 48. DOES ORGANIZATION PARTICIPATE IN ANY OTHER FEDERALLY- PROPRIETARY TITLE XX CENTER.) FUNDED PROGRAMS? ❑ NO ® YES(If "yes,"specify) Head Start, Job Training Partnership Act, Community Services Block Grant, etc. 4C. DOES YOUR ORGANIZATION NOW PARTICIPATE OR HAS YOUR 4D. DOES YOUR ORGANIZATION OPERATE THE CCFP IN ANY ORGANIZATION PARTICIPATED IN PROGRAMIS) FUNDED THROUGH OTHER STATE(S)? THE FOOD AND NUTRITION SERVICE IN THE PAST THREE YEARS? ®NO O YES(If "yes,"please identify which State(s)) ❑NO ® YES(If "yes"give name of program and dates of participation.) CCFP 5/1/8D to Present 5. NUMBER OF FACILITIES WITH FOOD SERVICE UNDER YOUR ADMINISTRATION Al CHILD CARE CENTERS IBIOUTSIDESCHOOL-HOURSCARE CENTERS ICI PROPRIETARY TITLE XX CENTERS ID)DAY CARE HOMES 4 -0- -0- -0- 6A. TOTAL NUMBER OF CHILDREN ENROLLED AT FACILITIES UNDER YOUR ADMINISTRATION (From item 10(d) Form FNS-341;Sponsor of homes;report only total enrollment in (d) below) al FREE CATEGORY lb)REDUCED-PRICE CATEGORY Icl NOT ELIGIBLE FOR FREE OR Id)TOTAL NUMBER OF REDUCED-PRICE CATEGORY CHILDREN(a+b♦c) I1) CENTERS 280 -0- -0 280 (2) PROPRIETARY TITLE XX CENTERS 13) HOMES 14)PROVIDERS OWN CHILDREN > (In 4a and 46 give only the numbers for the providers own children) 68. IS THIS A PRICING OR NONPRICING PROGRAM? (Check one) PRICING ® NONPRICINC 7A. CENTER SPONSOR REQUESTS ADVANCE PAYMENTS 7B. CENTER SPONSOR REQUESTS PARTIAL ADVANCE PAYMENTS ❑ YES © NO ® NO O YES (Amount per month $ 7C. HOME SPONSOR REQUESTS ADVANCE PAYMENTS 7D. HOME SPONSOR REQUESTS PARTIAL ADVANCE PAYMENTS YES ® NO [i] NO ❑ YES (Amount per month $ 7E. LIST ANY MONTHS WHEN THE CCFP WILL NOT OPERATE June, July, August 8. APPLICANT ORGANIZATION WOULD PREFER TO RECEIVE: (Check one box only (Approved applicants which prefer cash payments instead of donated foods will receive such payments. However, those which choose foods may be required to accept cash instead).) [24 USDA-DONATED FOOD - ❑ CASH PAYMENTS Vora 1 9:SPONSORING ORGANIZATION STAFFING PAT.:RN FOR CCFP(List all sponsoring organization pet_anel who will be involved in administering the CCFP in the chart below. Complete chart as specified, recording duties of personnel listed in ADMINISTRATIVE DUTIES directly related to the CCFP. Administrative duties include managing finances and operation of CCFP. Attach add@roaat sheets if necessary.) sA LARY PER HOUR NUMBER OF NUMBER OF HOURS INCLUDING FRINGE DAYSPER YEAR SOURCE OF ENTER ONLY SPECIFIC CCFP NUMBER OF PER DAY EACH EV BENEFITS EACH EMPLOYEE FUNDS FC... ANNUAL TYPE OF POSITION ADMIDUTIEATIVE THISONCE!IS PLOVEE tV COLUM4 I/ji:atr arofunrezrt IN COLUMN IaI SALARY EIFgc ES T6 DUTIES THIS PIE i�TrJV Icl WILL'DUTIES and unpaid WILL WORK ON (CCFP,etc.) BE LECU RF PROGRAV DUTIES tro iz * , PROGRAMOUTIEs UNOER CCFP VI It) 10 tT! Is) Iil 191 In) DIRECTOR- (or equivalent) -0_ ASSISTANT DIRECTOR for equivalent) CLERICAL (or equivalent) OTHER (Specify) 10. ANNUAL CCFP ADMINISTRATIVE BUDGET(Enter only costs which will be incurred under CCFP.) USDA HOMES CENTERS APPROVED AMOUNT ADMINISTRATIVE LABOR (Enter total of column 9(h)) OFFICE SUPPLIES(Including reproduction costs) -0- POSTAGE -0- I TRANSPORTATION FOR FACILITY MONITORING -0- MILEAGE ALLOWANCE FOR FACILITY MONITORING ( d per mile) CCFP'S SHARE OF: TELEPHONE -0- OFFICE RENTAL AND MAINTENANCE -0- UTILITIES FOR OFFICE AREA OTHER (Specify) —0— TOTAL ADMINISTRATIVE BUDGET 11. ANNUAL CCFP BUDGET FOR FOOD SERVICE OPERATIONS AT fACILITIES UNDER YOUR AD.AJNIST9ATION (Enter only costs which wilt be incurred under CCFP.) For simplicity, many additional costs are not listed (such aS DOrpons of CF TIERS teacher and aides salaries) because full direct costs are not cov7red by reign ursement. FOOD PURCHASES 17,500 FOOD SERVICE LABOR (Salaries of staff preparing or serving meals) 20,250 NONFOOD SUPPLIES—Nonfood items needed to support meat service (Napkins, straws, dishwashing detergent, etc.) • 1,000 CCFP's SHARE OF RENTAL FOR FOOD PREPARATION AND SERVICE AREAS —0— CCFP'$SHARE OF MAINTENANCE FOR PREPARATION AND SERVICE AREAS -O- OTHER (Specify) Frozen Storage 8Q0 TOTAL FOOD SERVICE OPERATING BUDGET 39,550 12. LIST SOURCES OF CASH INCOME SPECIFICALLY FOR THE FOOD SERVICE OTHER THAN CCFP REIMBURSEMENT. Charges for meals to non-CCFP staff FORM FNS-342 (7-83) - - Pegg 2 IJ. ULJVI\IU1 1114- 1 l v11 L-V�i.“•11 �..v...-.. _. ._ _ . .. . DAY,CCFP MEALS CLAIMED AND FAMILY SI. AND INCOME INFORMATION.IN ADDITION,FC .OMES,DESCRIBE THE PROCEDURES FOR DETERMINING ELIGIBILITY OF PROVIDER'S CHILDREN FOR REIMBURSEMENT. FOR EACH REC@RD,PLEASE DESCRIBE:WHAT METHOD WILL BE USED TO COLLECT THESE RECORDS?HOW FREQUENTLY WILL THESE RECORDS BE COLLECTED?WHERE WILL THESE RECORDS BE MAINTAINED ON FILE? Teachers fill out meal count worksheets and attendance sheets and turn in to Health Coordinator monthly. This data is compiled by Health Coordinator in filling out form for meals claims. Families must be income eligible before entrance into the program. Family income and family members are listed on the initial enrollment form. Record will be maintained at Greeley Center with Health Coordinator. 14A.D CRI E YOUR SYSTEM FOR DISBURSING CCFP REIMBURSEMENT TO FACILITIES UNDER YOUR ADMINISTRATION WITHIN 15 DAYS OF RECEIPT FROM USDA.(Reimbursement for a facility cannot exceed the CCFP meals claimed for that facility by the sponsoring organization, All operating reimbursement claimed for a day care home must be distributed to it) All centers are operated under the direction of the Head Start Program. Therefore the CCFP reimbursement is made to that one program and does not need to be disbursed to the other facilities. All costs for each of the four (4) centers are paid under the one (1) Head Start 148.DESCRIBE YOUR SYSTEM FOR DISBURSING CCFP ADVANCE PAYMENTS TO FACILITIES UNDER YOUR ADMINISTRATION.THE PAY-Rudiet. MENTS MUST BE DISBURSED TO DAY CARE HOMES NOT LATER THAN THE 5th WORKING DAY FOLLOWING RECEIPT OF THEIR RECORDS FOR THE MONTH OF THE ADVANCE PAYMENT. N/A 15.WILL THE SPONSORING ORGANIZATION CONTRACT WITH A FOOD SERVICE MANAGEMENT COMPANY FOR MEALS? O NO © YES(If'yes,"and if the value of the contract will exceed$10,000,contact the Regional Office immediately.) .^ 16.DESCRIBE YOUR SCHEDULE FOR TRAINING ADMINISTRATIVE AND FOOD SERVICE PERSONNEL IN CCFP REQUIREMENTS(Give dates of training sessions)and topics to be covered.) Training will be done September2A 1934, with teaching staff, and September 20 , 1984, for cooking staff. When new information is made available, training will be provided to all necessary staff. Reviews will be conducted at least once more. 17A.DESCRIBE YOUR PROCEDURE FOR CONDUCTING PRE-APPROVAL VISITS TO EACH PROPOSED CHILD CARE FACILITY(IES1. IF AVAILABLE,ATTACH A COPY OF A PREAPPROVAL EVALUATION FORM. The preapproval evaluation form will be used for each site (see attached) . SS 178.PROVIDE A SCHEDULE FOR MONITORING FOOD SERVICE OPERATIONS AT FACILITIES UNDER YOUR ADMINISTRATION(Each child care center must be reviewed at least three times each year,including one review during the first six weeks of CCFP operations. These reviews cannot be more than six months apart.Each outside-school-hours care center must be reviewed at least six times each year,including one review during the first month of CCFP operations. These reviews cannot be more than three months apart.Each day care home must be reviewed at feast t(t-^ee times each year,including one review during the first month of operations. These reviews cannot be more than six months apart.Make sure that the time allotted for monitoring in item 9 is sufficient to meet these requirements.) Monitoring of food service operations is done three (3) times during the school year of September - May; in 0ctober,January, and April . 17C.PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE POPULATION TO BE SERVED,AND DESCRIBE EFFORTS TO BE USED TO (1) ASSURE THAT MINORITY POPULATIONS HAVE EQUAL OPPORTUNITY TO PARTICIPATE,AND(2)CONTACT MINORITY AND GRASSROOTS ORGANIZATIONS ABOUT THE OPPORTUNITY TO PARTICIPATE IN THE PROGRAM, 75% Hispanic 25% Anglo We go to lower income housing areas; to all schools in Weld County; follow regulations in Head Start performance standards concerning minority requirements; and referrals from Social Services. 18.I certify that the information on this application and the attached forms FNS-341 and FNS-432 is true to the best of my knowledge;that I will accept final administration and financial responsibility for total Child Care Food Program operations at all facilities under my sponsorship;and that reimbursement will be claimed only for meals served to enrolled children;that the CCFP will be available to all eligible children without regard to race,color,sex,national origin,age or handicap at the approved food service facilities and that these facilities have the capability for the meal service planned for the number of children anticipated to be served. I understand that this information is being given in connection with the receipt of Federal funds and that deliberate misrepresentation Tray subject me to prosecution under applicable State and Federal criminal statutes. DATE NAME AND TITLE OF ADMINISTRATOR(Authorized SIGNATURE OF ADMINISTRATOR{Authorized sponsoring sponsoring organization representative)(Print or type) 6rgn ' tion representative) 09/12/84 Norman Carlson, Chairman IRnard of rnunfy rnmmiccionors FORM FNS-342(7-83) Page 3 Agrf. .ent Number 08-65103-00-0 INFORMATION UPDATE - Fiscal Year (FY) 1985 The Institution certifies that it is currently operating the Child Care Food Program (CCFP) and will continue to operate it during FY 1985 (October 1, 1984 , through September 30, 1985) in accordance with the CCFP Regulations, Part 226, dated August 20, 1982. The Institution further certifies that: 1. All centers are currently licensed or approved in accordance with the provisions of Sections 226.15(b) (4) or 226.16(b) (3) of the Regulations; 2. For any new center for which the Institution will be applying for participation, it will submit a completed Form FNS-341, Application for Participation for Child Care Center, prior to operation, as required by Section 226.16(b) of the Regulations; 3. It will advise the MPRO of any information changes affecting currently operating centers; e.g. , changes of address, of meal types, of meal service times, etc. 4. Form FNS-342 , Application for Participation & Management Plan for Sponsoring Organizations, as submitted for FY 1984, is accurate, is being adhered to, and will be followed during FY 1985. The Institution also certifies that if there should be any change in this application data or management plan, a new Form FNS-342 will be completed and submitted; 5. Preapproval visits and staff training will be scheduled and provided in accordance with Section 226.16(d) of the Regulations and documentation of these activities will be maintained on file; 6. If meals are supplied by a vendor, a copy of the contract will be submitted with this Information Update and the FNS-344, Agreement . 7. It elects the following with respect to advance payments for FY 1985: a. ( K) No advance payments b. ( ) Partial advance payments c. ( ) Full advance payments 8. The USDA Family Size and Income Guidelines effective July 1, 1984, will be utilized in classifying children into ineligible, free and reduced-price categories. The current enrollment figures are: ineligible, 980 free, and 0 reduced price. The Department's Agreement to reimburse the Institution is contingent upon the continued availability of funds appropriated for CCFP purposes in a sufficient amount , and no Legal liability on the part of the Government for the payment of any money shall arise unless and until such appropriations shall have been provided. Signature on Behalf of CCFP Institution U. S. Department of Agriculture By 7'7 4-'w'sc,. By Norman Carlson, C airman Title Board of County Commissioners Title Date 09/12/64 Date CO/NE _ FORM APPROVED OMB NO.05844055 U.S.DEPARTMENT OF AGRICUL -FOOD AND NUTRITION SERVICE AGREEMENT NUMBER APPLICATION FO, ARTICIPATION FOR CHILD CARE CENTER (CHILD CARE FOOD PROGRAM) 08-65103 INSTRUCTIONS: Complete in duplicate. Type or print clearly. If a sponsored facility, the original (and required attachments) must be submitted with Form FNS-342 "Application for Participation and Management Plan for Sponsoring Organizations". Include two copies of your free and reduced price policy statement,one copy of your proposed public release,and continuation sheets if necessary. TYPE OF CENTER 2 NAME AND ADDRESS OF CENTER (If Mailing Address Different from Address of Feeding Location,Please include both.Also include County.) CHILD CARE ❑ PROPRIETARY ❑ OUTSIDE-SCHOOL-HOURS CENTER TITLE XX CENTER!) CARE CENTER Greeley Head Start Center \A:'E AND TITLE OF PERSON RESPONSIBLE AT CENTER P. 0. Box 1805 (520 13th Avenue) Greeley, CO 80632 Juanita Santana, Director TELEPHONE NUMBER.AC (303) 353-0540 4. IS T-IS A PRIVATE ORGANIZATION?("PRIVATE"MEANS NON-GOVERNMENTALI 6A. IS CENTER LICENSED OR APPROVED BY FEDERAL.STATE,OR LOCAL AUTHORITY? ❑ YES ®NO ❑ YES ❑NO (If"YES,"except forpro➢netaryritte XX Center,attach a copy of letter from IRS (If"YES,"attach a copy of licensing or approval document) documenting tax-exempt status or copy of application to IRS and cover letter which indicates that an application has been filed with IRS or documentation that center participates in another Federal Program requiting nonprofit status) N/A - Head Start SA DOES YOUR CENTER NOW PARTICIPATE OR HAVE YOU PARTICIPATED GB. IF 'NO"HAS INSTITUTION APPLIED TO LICENSING AUTHORITIES FOR LICENSING IN PROGRAMIS)FUNDED THROUGH THE FODD AND NUTRITION OR APPROVAL? SERVICE IN THE PAST THREE YEARS? 9 YES YES (If"YES, name of program O NO and dates of participation)CCFP 5/1/80 t0 Present (If"YES,"attach a copy of first page of application and cover letter or other 53. DOES CENTER PARTICIPATE IN THE HEADS1'ART PROGRAM? proof of application.) z; YES O NO ❑NO SC DOES CENTER PARTICIPATE IN ANY OTHER FEDERALLY-FUNDED (If"NO"contact your FNS Regional Office. Not eligible to participate until PROGRAMS? some form of Licensing/Approval is obtained.) rJ YES (Specify program) -R] NO 7.OPERATING DATA 8.MEAL SERVICE A. HOURS OF OPERATION IN/I MEAL SERVED TIME OF MEAL SERVICEISI a MEALS EXPECTED TO a FROM 8:30 'rD 3:30 SE SERVED A.E7 BREAKFAST 9:30 210 B. NUMBER OF OPERATING DAYS C. NUMBER OF OPERATING WEEKS PER WEEK PER YEAR B. ❑ AM SUPPLEMENT 4 36 weeks D. ANNUAL DATES OF OPERATION STARTING ENDING c. ® LUNCH 11:30 210 September 25, 1984 May 17, 1985 E. LIST ANY MONTHS DURING WHICH THE CHILD CARE F000 PROGRAMD.Z] PM SUPPLEMENT 2,00 210 WILL NOT OPERATE(Include dates of closing and reopening) '.l E. ❑ SUPPER June, July, August 10. NUMBER OF CHILDREN ENROLLED IN: 9 METHOD BY WHICH MEALS WILL BE PROVIDED(VI A. FREE CATEGORY B. REDUCED PRICE CATEGORY A. LRJ PREPARATION AT MEAL SERVICE LOCATION 210 -0- B 9 PREPARATION AT CENTRAL KITCHEN C.NOT ELIGIBLE PRICE CATEGORY R FREE D.TOTAL NUMBER OF ENROLLED REDUCED CHILDREN (AC) C. 9 UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM .B+ 0. 9 UNDER CONTRACT WITH FOOD SERVICE MANAGEMENT COMPANY -0- 210 12. IS THIS A PRICING OR NONPRICING PROGRAM?(Check one) -GE RANGE OF ENROLLED CHILDREN ❑ PRICING ®NONPRICING FPOM 31 years old TD 5 years old 13. FOOD SERVICE STAFFING PATTERN(Enter only personnel who will perform Child Care Food Program food service functions In this center) NAME OF POSITION SPECIFIC CCFP FOOD SERVICE DUTIES NUMBER OF PERSONNEL IN TS P POSITION 1M BI CI Cook Prepares menus , food 2 Teacher Helps with serving children 7 Teacher Aide Helps with serving children 7 Health Coordinator Reviews menus, collects meal count 1 Health Assistant Assists Health Coordinator 1 FORM ENS-341 (7-83)Previous editions are obsolete. 14 CENTER RECUESTS. 15.CENTER REQUESTS:('v- _) ADVANCE PAYMENTS 0 YES p] NO ® DONATED FOODS 0 CASH INSTEAD OF DONATED FOODS PARTIAL ADVANCE • ❑ YES (If"YES"indicate amount '[$ NO NOTE. Approved centers which prefer cash Instsad of donated foods will racein:nth PAYMENTS of advance payment per -cash payments. Centers which choose donated foods may be required to accept cwh month) instead.Donated food or cash In lieu of food is provided in addition to CCFP reimbursements IS. PROVIDE A\ ESTIMATE OF THE RACIALIETHNIC MAKEUP OF THE POPULATIO\TO BE SERVED.OESCRIBE EFFORTS TO BE USEDI(II TO ASSURE THAT MINORITY POPULATIONS HAVE EQUAL OPPORTUNITY TO PARTICIPATE,AND(a1 TO CONTACT MINORITY AND GRASSROOTS ORGANIZATIONS ABOUT THE OPPORTUNITY TO PARTICIPATE IN THE PROGRAM. Approximately 77% Hispanic 23% Anglo We go to lower income housing areas and to all schools in Weld County. Head Start performance standards are followed concerning •minority requirements. Referrals from Social Services are also received • I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE;THAT I WILL ACCEPT FINAL ADMINISTRATIVE AND FINANCIAL RESPONSIBILITY FOR TOTAL CHILD CARE FOOD PROGRAM OPERATIONS AT THIS CENTER IF NOT UNDER A SPONSORING ORGANIZATION;THAT REIMBURSEMENT WILL BE CLAIMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;AND THAT THE CCFP WILL BE AVAILABLE TO ALL ELIGIBLE CHILDREN REGARDLESS OF RACE,COLOR,NATIONAL ORIGIN,SEX, HANDICAP,OR AGE. I UNDERSTAND THAT THIS INFORMATION IS BEING GIVEN IN CONNECTION WITH THE RECEIPT OF FEDERAL FUNDS,AND THAT A DELIBERATE MISREPRE- SENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL CRIMINAL STATUTES. 17.SIGNATURES NAME OF CENTER REPRESENTATIVE (Type or Print) NAME OF SPONSOR REPRESENTATIVE (If center will be sponsored_ Type or Print.) Juanita Santana, Head Start Director DATE sit ATURE OF CENTER REPRE NTATIVE DATE SIGNATURE OF SPONSORING ORGANIZATION REPRESENTATIVE A (If center will be sponsored) 9/12/84 /jr/d9 ,(/,, � iE9 • FORM APPROVED OMB NO,0584-0055 U.S.DEPARTMENT OF AGRICULT"` - FOOD AND NUTRITION SERVICE ""'.AGREEMENT NUMBER APPLICATION FOR ATICIPATION FOR CHILD CARE CENTER (CHILD CARE FOOD PROGRAM) 08-65103 INSTRUCTIONS: Complete in duplicate. Type or print clearly. If a sponsored facility, th2 original(and required attachments) must be submitted with Form FNS-342 "Application for Participation and Management Plan for Sponsoring Organizations". Include two copies of your free and reduced price policy statement,one copy of your proposed public release,and continuation sheets if necessary. 1.TYPE OF CENTER 2. NAME AND ADDRESS OF CENTER(If Mailing Address Different front Address of Feeding Location,Please include both. Also include County.) ®CHILD CARE O PROPRIETARY O OUTSIDE-SCHOOL.HOURS CENTER TITLE XX CENTERS CARE CENTER Johnstown Head Start Center 3. NAME AND TITLE OF PERSON RESPONSIBLE AT CENTER Letford Elementary School West Charlotte Street, Circle Drive Mabel Tapia, Teacher Johnstown, CO 80534 TELEPHONE NUMBER:AC (303) 587-2388 4. IS THIS A PRIVATE ORGANIZATION?("PRIVATE"MEANS NON-GOVERNMENTALI 6A. IS CENTER LICENSED OR APPROVED BY FEDERAL STATE,OR LOCAL AUTHORITY? ❑ YES ID NO ❑ YES ❑NO (If"YES,"except for; eprietaryTitle XX Center,attach a copy of letter from IRS (If"YES,"attache copy of licensing or approval document) documenting tax-exempt status or copy of application to IRS and cover letter which indicates that an application has been filed with IRS or documentation that center participates in another Federal Program requiring nonprofit status.) N/A — Head Start 5A. DOES YOUR CENTER NOW PARTICIPATE OR HAVE YOU PARTICIPATED 68. IF "NO"HAS INSTITUTION APPLIED TO LICENSING AUTHORITIES FOP.LICENSING IN PROGRAMIS)FUNDED THROUGH THE FOOD AND NUTRITION OR APPROVAL? SERVICE IN THE PAST THREE YEARS? O YES (X) YES (If"YES,"give name of program LINO and dates of participation) CCFP 5/80 to Present (If"YES,"attach a copy of first page of application and cover letter or other proof of application.) 58. DOES CENTER PARTICIPATE IN THE HEADSTART PROGRAM? �J YES ❑NO ❑NO SC. DOES CENTER PARTICIPATE IN ANY OTHER FEDERALLY-FUNDED (If"NO"contact your INS Regional Office.Not eligible to partici to until PROGRAMS? pa some form of Licensing/Approval is obtained.) ❑YES (Specify program) U NO 7.OPERATING DATA 8,MEAL SERVICE A. HOURS OF OPERATION IN/I MEAL SERVED TIME OF MEAL SERVICEISI P MEALS EXPECTED TO FI FROM TO 35 SERVED 8:30 3:30 A. BREAKFAST 8:30 20 B. NUMBER OF OPERATING DAYS C. NUMBER OF OPERATING WEEKS PER WEEK PER YEAR 4 36 (less holidays) B. ❑ AM SUPPLEMENT D. ANNUAL DATES OF OPERATION STARTING ENDING C. LUNCH September 25, 198.4 May 17, 1985 11:30 20 E. LIST ANY MONTHS DURING WHICH THE CHILD CARE FOOD PROGRAM D. PM SUPPLEMENT 2:00 20 WILL NOT OPERATE(Include dates of closing and reopening) L E. ❑ SUPPER June, July, August 10.NUMBER OF CHILDREN ENROLLED IN: 9. METHOD BY WHICH MEALS WILL BE PROVIDED A.FREE CATEGORY B.REDUCED PRICE CATEGORY A. ❑ PREPARATION AT MEAL SERVICE LOCATION 20 (y� B. ❑ PREPARATION AT CENTRAL KITCHEN C.NOT ELIGIBLE FOR FREE OR D.TOTAL NUMBER OF ENROLLED REDUCED PRICE CATEGORY CHILDREN (A F B+C) C. fa UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM D. ❑ UNDER CONTRACT WITH FOOD SERVICE MANAGEMENT COMPANY 0 20 IZ. IS THIS A PRICING OR NONPRICING PROGRAM?(Check one) II.AGE RANGE OF ENROLLED CHILDREN D PRICING ®NONPRICING FROM 31/2 years old IC 5 years old 13. FOOD SERVICE STAFFING PATTERN(Enter only personnel who will perform Child Care Food Program food service functions in this center) NAME OF POSITION SPECIFIC CCFP FOOD SERVICE DUTIES NUMBER OF PERSONNEL W THIS POSITION AlI Iel ICI Teacher Prepares snacks, helps children with serving 1 Teacher Aide Prepares snacks , helps children with serving 1 FORM ENS-341 (7-8 3) Previous editions are obsolete. a CENTER REQUESTS 15.CENTER REQUESTS:('V". ) ADVANCE PAYMENTS 0 YES ® NO J DONATED FOODS ❑ CASH INSTEAD OF DONATED FOODS PARTIAL.ADVANCE O YES (I/"YES"indicate amount II NO NOTE:Approved centers which prefer cash instead of donated foods will rents such PAYMENTS of advance payment per cash payments. Centers which choose donated foods may be re;•.tired CCFP mss month) instead. ements. food or cash in lieu of food is provided in addition to CUFF reimbursements. PROVIDE AN EST•VATE OF THE RACIAL'ETHNIC MAKEUP OF THE POPULATION 'D BE SERVED.DESCRIBE EFFORTS TO BE USED'111 TO ASSURE THAT MINORITY POPULATIONS. HAVE EQUAL OPPORTUNITY TO PARTICIPATE.AND(2)TO CONTACT MINORITY AND GRASSROOTS ORGANIZATIONS ABOUT THE OPPORTUNITY TO PARTICIPATE IN THE PROGRAM. 75% Hispanic 25% Anglo, please see the explanation under the Greeley Center. I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE;THAT I WILL ACCEPT FINAL ADMINITRATIVE AND FINANCIAL RESPONSIBILITY FOR TOTAL CHILD CARE FOOD PROGRAM OPERATIONS AT THIS CENTER IF NOT UNDER A SPONSORING ORGA•'tJSZATION;THAT REIMBURSEMENT WILL BE CLAIMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;AND THAT THE CCFP WILL BE AVAILABLE TO ALL ELIGIBLE CHILDREN REGARDLESS OF RACE,COLOR,NATIONAL ORIGIN,SEX, HANDICAP,OR AGE. I UNDERSTAND THAT THIS INFORMATION IS BEING GIVEN IN CONNECTION WITH THE RECEIPT OF FEDERAL FUNDS,AND THAT A DELIBERATE MISREPRE. SENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL CRIMINAL STATUTES. 17.SIGNATURES NAME OF CENTER REPRESENTATIVE (Type or Print) NAME OF SPONSOR REPRESENTATIVE (If center will be sponsored. Type or Print.) Juanita Santa a, Head Start Director DATE SI NATURE OF CENTER REPRESENTATIVE , DATE SIGNATURE OF SPONSORING ORGANIZATION REPRESENTATIVE p / (If center will be sponsored) r. _ FORM APPROVED OMB NO.0584-0055 U.S DEPARTMENT OF AGRICULTI''' FOOD AND NUTRITION SERVICE "'"AGREEMENT NUMBER APPLICATION FOR ATICIPATION FOR CHILD CAHE CENTER (CHILD CARE FOOD PROGRAM) 08-65103 INSTRUCTIONS: Complete in duplicate. Type or print clearly. If a sponsored facility, the original (and required attachments) must be submitted with Form FNS-342-"Application for Participation and Management Plan for Sponsoring Organizations". Include two copies of your free and reduced price policy statement,one copy of your proposed public release,and continuation sheets if necessary, TYPE OF CENTER 2. NAME AND ADDRESS OF CENTER III Mailing Address Different from Address of Feeding Location,Please include both.Also include County.) CHILD CARE O PROPRIETARY O OUTSIDE-SCHOOL-HOURS Pierce Head Start Center CENTER TITLE XX CENTERS CARE CENTER United Methodist Church 1. NAME ANO TITLE OF PERSON RESPONSIBLE A"CENTER P. 0. Box 250 (429 3rd Street) Pierce, CO 80650 Ramona Lucero, Teacher TELEPHONE NUMBER; AC (303) 834-1264 IS THIS A PRIVATE ORGANIZATION?1'PRIVATIP"MEANS NON-GOVERNMENTAL) 6A. IS CENTER LICENSED OR APPROVED BY FEDERAL STATE,OR LOCAL AUTHORITY? ❑ YES DK NO O YES O NO (If"YES,"except for proprieraryTitle XX Center,attach a copy of letter from IRS (If "YES,"attach a copy of licensing or approval document) documenting tax-exempt status or copy of application to IRS and cover letter which indicates that an application has been filed with IRS or documentation that center participates in another Federal Program requiring nonprofit statue.) N/A Head Start 5A. DOES YOUR CENTER NOW PARTICIPATE OR HAVE YOU PARTICIPATED 68. IF 'NO"HAS INSTITUTION APPLIED TO LICENSING AUTHORITIES FOR LICENSING IN PROGRAMISI FUNDED THROUGH THE FOOD AND NUTRITION OR APPROVAL? SERVICE IN THE PAST THREE YEARS? ❑ YES Dit YES (1/"YES,"give name of program O NO and dates of participation) CCFP 5/80 to Present (If "YES,"attach a copy of first page of application and cover letter or other proof of application,) 58. DOES CENTER PARTICIPATE IN THE HEADSTART PROGRAM? E3 YES O NO DNO SC. DOES CENTER PARTICIPATE IN AMY OTHER FEDERALLY-FUNDED (If "NO"contact your FNS Regional Office.Not eligible to participate until PROGRAMS? some form of Licensing/Approval is obtained.) O YES (Specify program) ® NO 7.OPERATING DATA 8.MEAL SERVICE A. HOURS OF OPERATION MEAL SERVED TIME OF MEAL SERVICEISI a MEALS EXPECTED TO 4e FROM TO RE SERVED 8:30 3:30 A. ® BREAKFAST 9:00 30 B. NUMBER OF OPERATING DAYS C. NUMBER OF OPERATING WEEKS PER WEEK PER YEAR B. C AM SUPPLEMENT 4 ;;6 (less holidays) D. ANNUAL DATES OF OPERATION STARTING ENDING C. ® LUNCH 11:45 30 September 25, 1984 May 17, 1985 E. LIST ANY MONTHS DURING WHICH THE CHILD CARE FOOD PROGRAM O, ® PM SUPPLEMENT 2:00 30 WILL NOT OPERATE(Include dates of closing and reopening) E. O SUPPER June , July, August 10,NUMBER OF CHILDREN ENROLLED IN: > METHOD BY WHICH MEALS WILL BE PROVIOEC IN/1 A.FREE CATEGORY B.REDUCED PRICE CATEGORY A. ® PREPARATION AT MEAL SERVICE LOCATION 30 0 B. O PREPARATION AT CENTRAL KITCHEN C.NOT ELIGIBLE FOR FREE OR D.TOTAL NUMBER OF ENROLLED REDUCED PRICE CATEGORY CHILDREN (A +B C) C. O UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM t(kk D. O UNDER CONTRACT WITH FOOD SERVICE MANAGEMENT COMPANY 0 30 12. 15 THIS A PRICING OR NONPRICING PROGRAM?(Check one) ''I. AGE RANGE OF ENROLLED CHILDREN O PRICING LO NONPRICING FROM 31 years old TO 5 years old 13. FOOD SERVICE STAFFING PATTERN(Eviler only personnel who will perform Child Care Food Program food service functions in this center) NAME OF POSITION SPECIFIC CCFP FOOD SERVICE DUTIES NUMBER OF PERSONNEL L\THIS POSITION IA) IBI ICI Cook Cooks food and prepares breakfast and snack 1 Teacher Helps children with serving 1 Teacher Aide Helps children with serving 1 FORM FNS-341 ,7-83) Previous editions are obsolete. :ENTER REOUESTS IS CENTER REQUESTS-(\f" ADVANCE PAYMENTS ❑ YES (22 NO In DONATED FOODS O CASH INSTEAD OF DONATED FOODS PARTIAL ADVANCE D YES (If"YES"Indicate amount NO NOTE: PAYMENTS � � advance ® Approved centers which prefer cash instead of donated foods will rre?:t rrvl: Ipayment per cash payments. Centers which choose donated foods may be rr,rsired to accept mot month) instead.Donated food or cash in lieu of food is provided In addition to CCFP reimbursements. • =AOVIDE AN ESTIMATE OF THE RACIAL-ETHNIC MAKEUP OF THE POPULATION TO BE SERVED DESCRIBE EFFORTS TO BE USED'IlI TO ASSURE THAT MINORITY POPULATIONS -AVE EQUAL OPPORTUNITY TO PARTICIPATE,AND 121 TO CONTACT MINORITY AND GRASSROOTS ORGANIZATIONS ABOUT THE OPPORTUNITY TO PARTICIPATE IN THE =ROGRAM. 70% Hispanic 30% Anglo, please see the explanation under the Greeley Center, I CERTIFY THAT THE INFORMATION ON THIS APPLICATION PS TRUE TO THE BEST OF MY KNOWLEDGE;THAT I WILL ACCEPT FINAL ADMINISTRATIVE AND FINANCIAL RESPONSIBILITY FOR TOTAL CHILD CARE FOOD PROGRAM OPERATIONS AT THIS CENTER IF NOT UNDER A SPONSORING ORGAN.ZATION;THAT REIMBURSEMENT WILL BE CLAIMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;AND THAT THE CCFP WILL BE AVAILABLE TO ALI,ELIGIBLE CH:LDREN REGARDLESS OF RACE,COLOR, NATIONAL ORIGIN,SEX, HANDICAP,OR AGE. I UNDERSTAND THAT THIS INFORMATION IS BEING GIVEN IN CONNECTION WITH THE RECEIPT OF FEDERAL FUNDS,AND THAT A DELIBERATE MISREPRE- SENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL CRIMLNAL STATUTES. 17.SIGNATURES OF CENTER REPRESENTATIVE (T>pe or Print) NAME OF SPONSOR REPRESENTATIVE (If renter witl be sponsored. Type or Print.) ...anita Santana, Head Start Director --_ 1 ATURE OF CENTER REPRESENT TIVE DATE SIGNATURE OF SPONSORING ORGANIZATION REPRESENTATIVE (If center will be sponsored) • i •2iL �� APPLICATION I PARTICIPATION FOR CHILD (-ARE CENTER (CHILD CARE FOOD PROGRAMI 08-65103 1 INSTRUCTIONS: Complete in duplicate. Type or print clearly. If a sponsored facility, the original (and required attachments) must be submitted with Form FNS-342 "Application for Participation and Management Plan for Sponsoring Organizations". Include two copies of your free and reduced price policy statement, one copy of your proposed public release,and continuation sheets if necessary. • Tv-E OF CENTER 2.NAME AND ADDRESS OF CENTER(/(Mailing Address Different from Address of Feeding Location,Please Include both.Also include County.) j u CHILD CARE 0 PROPRIETARY 0 OUTSIDE.SCHOOL.HOURS Frederick Head Start Center CENTER TITLE XX CENTERS CARE CENTER Saint Teresa 's Church 2 NAVE AND TITLE OF PERSON RESPONSIBLE AT CENTER Parish Hall Agnes Martinez, Teacher Frederick, CO 80530 TELEPHONE NUMBER: AC (303) 833-9997 IS T-'5 A PRIVATE ORGANIZATION?("PRIVATE"MEANS NON-GOVERNMENTALI 6A. IS CENTER LICENSED OR APPROVED BY FEDERAL,STATE,OR LOCAL AUTHORITY? YES NO O YES Cl NO r!/•'YES,"except forp roprietaryTitle XX Center,attach a copy of letter from IRS (If"YES,"attach a copy of licensing or approval document) documenting tanexempt status or copy of application to IRS and cover letter which indicates that an application has been filed with IRS or documentation that center participates in another Federal Program requiring nonprofit status.) N/A Head Start SA. OCES YOUR CENTER NOW PARTICIPATE OR HAVE YOU PARTICIPATED 68. IF"NO"HAS INSTITUTION APPLIED TO LICENSING AUTHORITIES FOR LICENSING IN PROGRAM'SI FUNDED THROUGH THE FOOD AND NUTRITION OR APPROVAL? SERVICE IN THE PAST THREE YEARS? YES [ YES (If"YES,"give name of program CJ NO ❑ and dates of participation)CCFP 5/80 t0 Present (If"YES,"attach a copy of first page of application and cover letter or other proof of application.) 50. DC ES CENTER PARTICIPATE IN THE HEA(ISTART PROGRAM? YES NO NO 5C. DOES CENTER PARTICIPATE IN ANY OTHER FEDERALLY'FUNOED (If".CO"contact your ENS Regional Office.Not eligible to participate until PF)GRAMS? some form of Licensing/Approval is obtained.) YES (Specify program) ® NO • 7.OPERATING DATA 8.MEAL SERVICE A ,OURS OF OPERATION I�l MEAL SERVED TIME OF MEAL SERVICEISI N MEALS EXPECTED TO =ROM TO BE SERVED 8:30 3:30 A.01 BREAKFAST 8:30 20 E NUMBER OF OPERATING DAYS C. NUMBER OF OPERATING WEEKS >ER WEEK PER YEAR B. C AM SUPPLEMENT 4 36 (less holidays) 0. ANNUAL DATES OF OPERATION STARTING ENDING C. [A LUNCH 11:30 20 September 25, 1984 May 17, 1985 ® PM SUPPLEMENT 2:00 20 E. LIST ANY MONTHS DURING WHICH THIS CHILD CARE FOOD PROGRAM NILL NOT OPERATE(Include dates of closing and reopening) E ❑ SUPPER June, July, August 10.NUMBER OF CHILDREN ENROLLED IN: •.ET..OD BY WHICH MEALS WILL BE PROVIDED I. 1 A. FREE CATEGORY B.REDUCED PRICE tkI CATEGORY A. ] PREPARATION AT MEAL SERVICE LOCATION 20 0 a PREPARATION AT CENTRAL KI"CHEN C.NOT ELIGIBLE FOR FREE OR D.TOTAL NUMBER OF ENROLLED REDUCED PRICE CATEGORY CHILDREN (A +B+C) c. P+l UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM D. • UNDER CONTRACT WITH FOOD SERVICE MANAGEMENT COMPANY 0 20 12. IS THIS A PRICING OR NONPRICING PROGRAM?(Check one) ABE RANGE OF ENROLLED CHILDREN O PRICING NONPRICING °= 3% years old TO 5 years old 13. FOOD SERVICE STAFFING PATTERN(Enter only personnel who will perform Child Care Food Program food service functions in this center) NAME OF POSITION SPECIFIC CCFP FOOD SERVICE DUTIES ROMPER OF PERSONNEL IN THIS PERSONNEL (Al IBI IC) Teacher Helps with serving children & preparing snacks 1 Teacher Aide Helps with serving children & oreparinq snacks 1 • FORM FNS.341 (7-63) Previous editions are obsolete. ..�.. rs CENTER REQUESTS - IS.CENTER REQUESTS('�. �.e).. - - -- ADVANCE PAYMENTS O YE.S ® NO ®DONATED FOODS O CASH INSTEAD OF DONATED FOODS PARTIAL ADVANCE O YES (If"YES"indicate amount IS NO NOTE:Approved centers which prefer cash instead of donated foods will randy ne[A PAYMENTS - of advance payment per cash payments, Centers which choose donated foods may be squired to accept I month) Instead. Donated or cash in heu teeth food of food is provided In rddittar,to CI? reimbursement CCFF s, IB. PROVIDE AN ESTIMATE OF THE RACNLL'ETHNIC MAKEUP OF THE POPULAT.O%TO BE SERVED. DESCRIBE EFFORTS TO BE USEDIIII TO ASSURE THAT MINORITY POPULATIONS j HAVE EQUAL OPPORTUNITY TO PARTICIPATE.AND 121 TO CONTACT MINOR In.AND GRASSROOTS ORGANIZATIONS ABOUT THE OPPORTUNITY TO PARTICIPATE IN THE J PROGRAM. 60% Hispanic 40% Anglo Please see the explanation under the Greeley Center, I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE;THAT I WILL ACCEPT FINAL ADMINO;TRATIVE AND FINANCIAL RESPONSIBILITY FOR TOTAL CHILD CARE FOOD PROGRAM OPERATIONS AT THIS CENTER IF NOT UNDER A SPONSORING ORGANIZATION;THAT REIMBURSEMENT WILL BE CLAIMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;AND THAT THE CCFP WILL BE AVAILABLE TO ALL ELIGIBLE CHILDREN REGARDLESS OF RACE,COLOR,NATIONAL ORIGIN,SEX, HANDICAP,OR AGE. I UNDERSTAND THAT THIS INFORMATION IS BEING GIVEN IN CONNECTION WITH THE RECEIPT OF FEDERAL FUNDS,AND THAT A DELIBERATE MISREPRE- SENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL CRIMINAL STATUTES. 17.SIGNATURES NAME OF CENTER REPRESENTATIVE (Type or Print) NAME OF SPONSOR REPRESENTATIVE (If center will be sponsored. Type or Print.) Juanita San a, Head Start Director DATE / SI ATURE J OF CENTER REPRESENTATIVE DATE SIGNATURE OF SPONSORING ORGANIZATIOTT'REPRESENTATIVE ( I. / (If center will be sponsored) it. / Agreement No. 03,15.10:1E2_____ NONDISCRIMINATION POLICY STATEMENT FOR THE CHILD CARE FOOD PROGRAM 1. Weld County Division of Human Resources assures the Food and Nutrition (Name of Sponsor) Service Regional Office that all children at the facilities described on the application forms are served the same meals at no separate charge regardless of race, color, national origin, age, sex, or handicap, and and there is no discrimination in the course of the meal service. 2. We will annually submit a public release to the news media serving the area(s) from which our institution draws attendance announcing the availability of meals at no separate charge to enrolled children. (A sample public release is shown on the reverse side of this form.) 3. We understand that we are not required by the Food and Nutrition Service to pay for publication of our release. 4. We will retain a copy of the public release sent to the media in our permanent files. 5. At least one of the following boxes must be checked. a. We have attached a copy of the public release and have indicated to whom and when it was sent. b. (__J A copy of the news release that was published is attached. (Please send the full newspaper page on which the release was printed.) c. f X we will issue a news release on the week of September 24, 1984 (date) A copy of our release and the published release, if any, will be sent to your office within 1 month of this date. • \d19-11--v",4 �' - Norman Carlson, Chairman omi Board of County Commissioners 9/12/84 For Sponsor (Signature) (Title) (Date) FOR USDA ONLY Approved by (Name) (Title) (Date) (This form is not to be used by FDCH sponsors.) ' ra. United States Food and Mountain 2420 West 26th Avenue \X141)) Department of Nutrition Plains Denver, GO 80211 \J Agriculture Service Region Telephone No. - (303) 353-0540 Agreement No. 08-65103-00-0 CERTIFICATE OF AUTHORITY Th s� ' ertify that Ate— Executive Director and Wer J. Speckman or / Juanita antana , Head Start Director (MANUAL SIGNATURE of Person to be Authorized) (Title) w is designated as the authorized representative of the Weld County Division of Human Resources P.O. Box 1805 Greeley Bn637 (Sponsoring Agency) (Address) (City, State, Zip) which is the governing body of the Child Care Food Program in child care centers or Family Day Care Homes. Authority is hereby given the above designated representative to enter into written agreements on behalf of the Sponsoring Agency with the Food and Nutrition Service of the United States Department of Agriculture, for the operation of a Child Care Food Program in the above named service institution, and to present claims for reimbursement and sign for the Sponsoring Agency any other documents or reports relating thereto. Weld County Division of Human Resources (Name of Sponsoring Agency) *SIGNATURE MUST BE DIFFERENT FROM PERSON DESIGNATED AS AUTHORIZED REPRESENTATIVE (SIGNATURE of Official of Sponsoring Agency) Norman Carlson, Chairman Weld County Board of Commissioners (Title of Official) 9/12/84 Date fW.I yC 'QN.'C'.)r 0.• Y .c ♦ 'N :'Sre i .,,,ye. .. '•i+.a 3f �'. �.�'.:E4'`'°'..Ls f"'c � f' Y 1k:• < i.' wZ„tri.' Q w a A s 0t Fo m CO 0 o- Y - O K V 4 O 74 3 > Z zz y < . F O 0. z - .0 '< = C C- •...4 .-m d to r.- ' i g o G' 'O �/+i w` . '•IC'S 4S i� )..=.4 k :V ...4 to st�'-Iirei¢.." '—" N aD W rc • w 0 < U o • g ¢ a 0 >D 4" Q::-:. 1 C • W ' N S o8 > z9 °.° Qu a 2 6 •� f �. �• U VJ O4 W a WO t 2 S a- >- u LL l - p... 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S•E .i • s - L -13- �e� United States Food and Mountain 2420 West 26th Avenue + tiff Department of Nutrition Plains Denver, CO 80211 \��`" i Agriculture Service Region MPRO-CC-84-5 July 17, 1984 Dear Child Care Food Program Administrator: The guidelines for determining eligibility for free and reduced-price meal reimbursement: for the period of July 1 , 1984, through June 30, 1985, are as follows: Eligibility Scale for Eligibility Scale for Family Size Free Meals Reduced Price Meals Annual Month Biweekly Week Annual Month Biweekly Week 1 6,474 540 249 125 9,213 768 354 178 2 8,736 728 336 168 12,432 1 ,036 478 240 3 10,996 917 423 212 15,651 1 ,305 602 301 4 13 ,260 1 ,105 510 255 18,870 1 ,573 726 363 5 15,522 1 ,294 597 299 22 ,089 1 ,841 850 425 6 17 ,784 1 ,482 684 342 25,308 2 ,109 973 487 7 20,046 1 ,671 771 386 28,527 2 ,378 1,097 549 8 22,308 1 ,859 858 429 31 ,746 2,646 1,221 611 For each Additional Family Member Add: 2,262 189 87 44 3,219 269 124 62 As a reminder, we are restating for your reference the definition of income. "Income" means income before deductions such as income taxes, social security taxes, insurance premiums, charitable contributions, and bonds. It includes the following: (1) Monetary compensation for services, including wages, salary, commissions, or fees;,(2) net income from nonfarm self—employment; (3) net income from farm self— employment; (4) social security; (5) dividends or interest on savings or bonds or income from estates or trusts; (6) net rental income; (7) public assistance or welfare payments; (8) unemployment compensation; (9) government civilian employee or military retirement or pensions or veterans' payments; (10) private pensions or annuities; (11) alimony or child support payments; (12) regular contributions from persons not living in the household; (13) net royalties; and (14) other cash income. Other cash income would include cash ami nta received or withdrawn from any source includ ''ng vov g f limst ents, trust accounts, and other resources. JUL 2 3 1984 RECEIVED • Hello