HomeMy WebLinkAbout850917.tiff rity,h , . tuGfinD m
wit�• r,_hrkia Johnson, Chairman Date September 10, 1985
Board of County Commissioners
COECEADO From Walter J. Soeckman, Executive Director, Human Resources ,
subject: USDA Child Care Food Program Agreement
Enclosed for Board approval is an agreement between Head Start and the
U.S. Department of Agriculture 's Food and Nutrition Service/Child Care
Food Program.
The agreement provides for the reimbursement costs of meals (breakfasts,
snacks, and lunches) served to participants of the Head Start Program.
This agreement will begin October 1, 1985, and end September 30, 1986.
This is an agreement that has been on-going since May, 1980.
If you have any questions, please feel free to contact me at 353-0540.
850917
FORM APPROVED OMB NO.0584-0056
U.S.DEPARTMENT OF AGRICULTI FH lNS USE ONLY
FOOD AND NUTRITION SERVICE AGREEMENT NUMBER
AGREEMENT -
08-65103-00-0
(CHILD CARE FOOD PROGRAM) wELD CNTY AC OF COMMISSIONERS
HEAD START
INSTRUCTIONS: The Institution should complete Sections A and B in dupli-
cate,sign both copies and return to ENS Regional Office.The Regional Office PO BOX 1805
will complete Sections C and D, sign both copies and return one copy to the 8 0 631
Institution.The Institution MUST RECEIVE A COPY OF THE CHILD CARE G R E E L E Y CO
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 10/01/85 to 09/30/86
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 Apiculture (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 wEll 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 be 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.
•
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 GFR Part 226)
FORM'FNS344 (7-83) Previous editions obsolere. PageI
ern) n
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 HOME HOURS AND TYPE OF MEALS SERVED
(Indicate "C"if Child Note: No more than 3 meals per day
CHILD CARE FOOD PROGRAMCare Center, "O"if per child shall be claimed.
Outside-School-Hours
(Name and address of cents or home). Care Center, "P"if Proprietary Title XX BREAK- AM PM
Center, or "H"if FAST SNACK LUNCH SNACK SUPPER
Day Care Home
la) lb) (c) Id) (e) (t) (g)
1. Greeley Head Start Center C 9:30 11:30 2:00
P.O. Box 1805
520 13th Avenue
Greeley, CO 80632
(303) 356-0600
2.**Firestone Head Start Center C 8:30 11:30 2.00
478 1st Street
Firestone, CO 80520
3.**Johnstown Head Start Center C 8:30 11:30 2:00
Letford Elementary School
West Charlotte Street & Circle
Drive
Johnstown, CO 80534
4. Pierce Head Start Center C 9:00 11:45 2:00
United Methodist Church
. 429 3rd Street
Pierce, CO 80650
•
•
FORM FNS-344 (7-83).Previous cdi ions obsolete. - Page 2
SECTION C(For FNS Regional Office Use)
THE INSTITUTION AND THE DEPARTMENT MUTUALLY AGREE THAT THE INSTITUTION WILL RECEIVE FOR ITS CHILD CARE CENTERS
AND OUTSIDE-SCHOOL-HOURS CAFIE CENTERS AND PROPRIETARY TITLE XX CENTERS.
0 DONATED COMMODITIES, OR 0 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
j $
A. ADMINISTRATIVE LABOR -0-
8. OFFICE SUPPLIES -0-
C. POSTAGE -0-
D. TRANSPORTATION FOR FACILITY MONITORING —0—
E. MILEAGE ALLOWANCE FOR FACILITY MONITORING —0—
CCFP's SHARE OF: b
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 edirions obsolete. Page 3
rt C'
NONDISCRIMINATION CLAUSE
THE INSTITUTION:
HEREBY 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 purposes 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 r
to discrimination under any program or activity for which the BY ACCEPTING THIS ASSURANCE, the applicant agrees to corn-
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 and 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 be 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
AUTHOR EE REPRESENTATIVE FOOD AND NUTRITION SERVICE REGIONAL OFFICE
vv J SIGNATURE SIGNATURE
NAME: Jacqueline Johnson NAME:
(Print or Type) (Print or Type)
Chairman, Weld County
TITLE: Board of Commissioners DATE:09/11/85 TITLE: DATE:
FORM FNS-344 (7-83) Previous editions obsolete. Page 4
FORM APPROVED OMB NO. 0584-0055
US. DEPARTMEN AGRICULTURE GREEMENT NUMBER
FOOD AND NUTP9'TION SERVICE
APPLICATION FOR PARTICIPATION & MANAGEMENT PLAN FOR
SPONSORING ORGANIZATIONS 08-65103-00-0
IN THE CHILD CARE FOOD PROGRAM (CCFP)
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 Cue 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)
Weld County Division of Human Resources Jacqueline Johnson, Chairman
Head Start Program Weld County Board of Commissioners
P.O. Box 1805 28. NAME AND TITLE OF CCFP REPRESENTATIVE (Individual who
Greeley, CO 80632 can be contacted for Programmatic Information)
Juanita Santana, Head Start Director
Jeannie Tacker, Fiscal Officer
TELEPHONE NUMBER: AC (303'1 353-0540
4A. DOES ORGANIZATION PARTICIPATE IN THE HEADSTART 3. IS THIS A PRIVATE ORGANIZATION?(Private means non-
PROGRAM? governmental)
® NO OYES(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 6J YES(If'yes,"specify)
Head Start, Job Training Partnership Act, Commun-
ity Services Block Grant, etc.
4C. DOES YOUR.ORGANIZATION NOW PARTICIPATE OR HAS YOUR 4D. DOES YOUR ORGANIZATION OPERATE THE CCFP IN ANY
ORGANIZATIONIIBARTICIPATrED IN PROGRAM(S) FUNDED THROUGH OTHER STATE(S)?
THE FOOD AND NUTRITION SERVICE IN THE PAST THREE YEARS?
❑ NO 0 YES(If "yes,"please identify which State(s))
❑NO ® YES(If "yes"give name of program and dates of
participation.)
CCFP - 5/1/80 to Present
5. NUMBER OF FACILITIES WITH FOOD SERVICE UNDER YOUR ADMINISTRATION
IA)CHILD CARE CENTERS ,3i OUTSIDE-SCHOOL-HOURS CARE CENTERS (C)PROPRIETARY TITLE XX CENTERS IDI DAY CARE HOMES
4
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)
4)FREE CATEGORY lb) REDUCED-PRICE CATEGORY (N NOT ELIGIBLE FOR FREE OR WI TOTAL NUMBER OF
REDUCED-PRICE CATEGORY CHILDREN(a+b+e)
(1) CENTERS 300 -0- -0- 300
(2) PROPRIETARY TITLE XX
CENTERS
(3) HOMES
" 'a( , . ,w a ��''w.� ,. . 4*7t16�` � , •
°`
(4)PROVIDERS OWN CHILDREN x +
(In 4a and 4b give only the ,y
numbers for the providers °s
own children) - -'�•� , I"" sa =� `'�
68. IS THIS A PRICING OR NONPRICING PROGRAM?(Check one)
❑ PRICING ® NONPRICWCi
7A. CENTER SPONSOR REQUESTS ADVANCE PAYMENTS 7B. CENTER SPONSOR REQUESTS PARTIAL ADVANCE PAYMENTS
❑ YES ® NO ® NO ❑ YES (Amount per month $
7C. HOME SPONSOR REQUESTS ADVANCE PAYMENTS 7D. HOME SPONSOR REQUESTS PARTIAL ADVANCE PAYMENTS
❑YES ® NO ®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].)
x' USDA-DONATED F000 ❑ CASH PAYMENTS
FORM FNS-342 (7-83) Previous editions are obsolete. Page 1
rIDIN
9.SPONSORING ORGANIZATION STAFFING PA`. .cRN FOR CCFP(List all sponsoring organization pe.-innel 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 additional sheets if necessary.)
SALARY PER HOUR NUMBER OF
NUMBER OF HOURS INCLUDING FRINGE E AYSPER YEAR SOURCE OF ENTER ONLY
SPECIFIC CCFP NUMBER OF PER DAY EACH MN BENEFITS EACH'EMPLOVEE FUNDS FOR ANNUAL
TYPE OF POSITION ADMINISTRATIVE PERSONNEL IN PLOVEE I.N COLUMN (lndi d volunteers IN COLUMN le) SALARY SALARIES TO
DUTIES THIS POSITION Icl WILL SPENT ON and unpaid ROG WORK ON (CCFP, etc.) BE IiN R CCFP
PROGRAM DUTIES work Ivith "V") PROGRAM DUTIES UNDER CCFP
lal lel Icl w1 lel Irl 191 IN
DIRECTOR
(or equivalent) -0—
ASSISTANT
DIRECTOR
(or equivalent) —0
CLERICAL
(or equivalent) —0—
OTHER
(Specify) —0-
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)) —0—
OFFICE SUPPLIES(Including reproduction costs) —0—
POSTAGE •
-0-
- -TRANSPORTATION FOR FACILITY MONITORING -0-
MILEAGE ALLOWANCE FOR FACILITY MONITORING (_E per mile)
CCFP'S SHARE OF: = ? It
TELEPHONE -n-
OFFICE RENTAL AND MAINTENANCE
UTILITIES FOR OFFICE AREA
OTHER (Specify)
TOTAL ADMINISTRATIVE BUDGET
11. ANNUAL CCFP BUDGET FOR FOOD SERVICE OPERATIONS AT FACILITIES UNDER YOUR ADMINISTRATION (Enter only costs which will
be incurred under CCFP.) For simplicity, many additional costs are not listed (such t€NfStions of
teacher and aides salaries) because full direct costs are not coverod by rcimburscmcnt.
FOOD PURCHASES 17.500
FOOD SERVICE LABOR (Salaries c f staff preparing or serving meals) 20,250
NONFOOD SUPPLIES—Nonfood items needed to support meal service
(Napkins, straws, dishwashing detergent, etc.) 1,000
CCFP's SHARE OF RENTAL FOR FOOD PREPARATION AND SERVICE AREAS
CCFP's SHARE OF MAINTENANCE FOR PREPARATION AND SERVICE AREAS
OTHER (Specify) .. .F.rozen..Stora.ge 800
TOTAL FOOD SERVICE OPERATING BUDGET
.19 12. LIST SOURCES.OF CASH INCOME SPECIFICALLY FOR THE FOOD SERVICE OTHER THAN CCFP REIMBURSEME Tq'�D
Charges for meals to non-CCFP staff
FORM FNS-342 (7-83) Page 2
II)13. DESCRIBE THE PROCEDURE FOR COLLEC RECORDS FROM EACH FACILITY SHOWING UMBER OF CHILDREN SERVED EACH
DAY,CCFP MEALS CLAIMED AND FAMILY SIZE AND INCOME INFORMATION.IN ADDITION, Ft: HOMES, DESCRIBE THE PROCEDURES
FOR DETERMINING ELIGIBILITY OF PROVIDER'S CHILDREN FOR REIMBURSEMENT. FOR EACH RECORD,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 the meal county worksheets and attendance sheets and turn them in to the
Health Coordinator. The data is then compiled for the meal claim forms. Families must be
income eligible before they enter the program. Family income and family members are listed on
the initial enrollment form. Records are maintained at the Greeley Center.
14A.DESCRIBE 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 the one
program and does not need to be disbursed to the other facilities. All costs for each of
the four centers are paid under the one Head Start budget.
14B,DESCRIBE YOUR SYSTEM FOR DISBURSING CCFP ADVANCE.PAYMENTS TO FACILITIES UNDER YOUR ADMINISTRATION.THE PAY- .
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?
NO ( J 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 session(s)and topics to be covered.)
Training is done i.n September with both the teaching and cooking staff. When new information
is made available, training is provided to all necessary staff. Reviews are conducted at
least once after training,
17A.DESCRIBE YOUR PROCEDURE FOR CONDUCTING PRE-APPROVAL VISITS TO EACH PROPOSED CHILD CARE FACILITY(I!ES).IF
AVAILABLE,ATTACH A COPY OF A PREAPPROVAL EVALUATION FORM.
The preapproval evaluation form will be used for each site.
17B.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 CCFPoperations.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 least three 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 times during the school year (September,
1985 - May, 1986) , Monitoring will occur in October, 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 wilt 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 may 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) rganization represent iv
09/11/85 Jacqueline Johnson , Chairman
FORM FNS-342(7-83) Page 3
FORM APPROVED OMB NO.0584-0055
U.S.DEP,t,aTMENT OF AGRICU Tu FOOD:.NO N 1RITION SERVICE aGREEnENT NUMBER
APPLICATION FOR fLTICIPATION FOR
• CHILD CARE CENTER
ICHoLD CARE' FOOD PROGRAM) 08-65103
INSTRUCTIONS: Complete in duplicate. i!'ype or print clearly. If a sponsored facility, the original rand required attachments) roust 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 nece-iary.
OF CENTER 2.NAME AND ADDRESS 0=CENTER (II Mailing Address Different from Address of
Feeding Location,Recce Delude both.Also include County.)
3 CHILD CARE Q PROPRIETARY ❑ OUTSIDE.SCHOOL•HOURS
CENTER TITLE XX CENTERS CARE CENTER Greeley Head Start Center
\A,E AND TITLE OF PERSON RE OO .S=3LE.,T CENTER P. 0. Box 1805 (520 13th Avenue)
Greeley, CO 80532
Juanita Santana, Director
TELEPHONE NUMBER. AC (303) 353-0540
i5 T-:S A PRIVATE ORGANIZATION?r-PNLVATE"MEANS NON-GOVERNMENTAL' 6A. IS CENTER LICENSED OR APPROVED BY FEDERAL,STATE,OR LOCAL AUTHORITY?
7-1 YES El NO O YES O NO
(If"YES,"except for ro et p p^ my7"rlie X7C Center,attach a copy of letter from IRS (If"Y£5,-attach a copy of licensing or approval document)
documenting tax-exempt status or copy of application to IRS and corer letter which
indicates that an application has been tiled wit?!IRS a docwnentation that center
participates in another Federal Programs requaizg nonprofit status.) N/A - Head Start
DOES YOUR CENTER NOW PARTICIPATE OR HAVE YOU PARTICIPATED 6B. IF•'NO"HAS INSTITUTION APPLIED TO LICENSING AUTHORITIES FOR LICENSING
I\PROGRAM{S) FUNDED THROUGH THE FOOD AND NUTRITION OR APPROVAL?
SERVICE IN THE PAST THREE YEARS?
[]YES
® YES (If"YES,"give narne of propane ❑NO
and dates of participation)CCFP 5/1/80 to Present (If YES,"attach a copy of first page of application and cover letter or other
proof of application.)
is. DOES CENTER PARTICIPATE IN THE HEAOSTA.RT PROGRAM?
YES ❑NO
NO
5C DOES CENTER PARTICIPATE IN ANY OM ER FEDERALLY-FUNDED (If'NO"contact your FINS Regional Office. Not eligible to participate until
PROGRAMS? some form of Licens4r:g/Approval is obtained.)
YES (Specify program) ] NO
7. OPERATING DATA 8.MEAL SERVICE
A. HOURS OF OPERATION (\/I MEAL SERVED TIME OF MEAL SERVICEISI 0 MEALS FJ(PECTCo TO
FROM eE SERVED
8:30 T) 3:30
A,® BREAKFAST 9:30 230
E. '.UMBER 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. n LUNCH 11 :30 230
•_S.eptenber -19, 1985 May 31-, 1986
E. LIST ANY MONTHS DURING WHICH THE CF ILO CARE FOOD PROGRA'.I 0. PM SUPPLEMENT 2:0O .230
WILL NOT OPERATE(Include dates of closing and reopening) L J
E. SUPPER
June, July, August 10. NUMBER OF CHILDREN ENROLLED IN:
.`.METHOD BY WHICH MEALS WILL BE PROVIDED hi A. FREE CATEGORY B.REDUCED PRICE CATEGORY
A. �n PREPARATION AT MEAL SERVICE LOCATION 230 -0-
B PREPARATION AT CENTRAL KITCHEN C.NOT ELIG13LE FOR FREE CR D.TOTAL NUMBER OF ENROLLED
REOUCEO PRICE CATEGORY
CHILDREN (A+$+C)
C. UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM
C. - UNDER CONTRACT WITH FOOD SERVICE MANAGEMENT COMPANY -0- 230
12. IS THIS A PRICING OR NONPRICING PROGRAM?(Check one)
-.SE RANGE OF ENROLLED CHILDREN ❑ PRICING ® NONPRICING
„.I 31/2 years old To 5 years old
FOOD SERVICE STAFFING PATTERN /Enter only personnel who will perfor-1 Child Care Food Program food service functions in this center)
NUMBER OF
NAME OF POSITION SPECIFIC CCFP FOOD SERVICE DUTIES IN THIS POOSITIOSPERSONNEL
POSITION
IAN I61 (CI
Cook Prepares menus , food 2
•
Teacher Helps i'lith 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 FNS.341 (7-83) Precious editiors are obsolete.
14.CENTER RECJEST5, r' 15.CENTER REV(mil"One)
ADVANCE PAYMENTS 0 YES [l ND 2 DONATED FOODS 0 CASH INSTEAD OF DONATED FOODS
PARTIAL ADVANCE _L] YES (If'YES"indicate amount ,2 NO NOTE:Approved centers which prefer cash instead of donated foods wilt receive such
PAYMENTS of advance payment per cash payments. Centers which choose donated foods nosy�be.ne uiredito accept cash
month) instead.Donated food or cash in Sets of food Is provided in addition.to CCFP
reimbursements.
IE. PROVIDE AN ESTIMATE OF THE RACIAI!ETHNIC MAKEUP OF THE POPULAT'7.TO BE SERVED. DESCRIBE EFFORTS TO BE USEDHII TO ASSURE THAT MINORITY POPULATIONS
HAVE EQUAL OPPORTUNITY TO PARTICIPATE.AND 121 TO CONTACT MI h.,^.F:-'•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 ORIGLN, SEX. HANDICAP,OR AGE.
I UNDERSTAND THAT THIS LNFORMATION,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 CRLIINAL STATUTES.
17. SIGNATURES
NAME OF CENTER REPRESENTATIVE (Type or Pint) NAME OF SPONSOR REPRESENTATIVE (I/center will be sponsored. Type Or Pint)
Juanita Santana, Head Start Director
DATE SIGNATURE OF CENTER REPRESENTATIVE DATE SIGNATURE OF SPONSORING ORGANIZATION REPRESENTATIVE
(If center will be sponsored)
FORM APPROVED OMB NO.0584-0055
U.S.DEPAR Tm.F.NT OF AGRICULTUR FOOD AND NUTRITION SERVICE 1'GREEMENT NUMBER
APPLICATION FOR TICIPATION FOR
CHILD CA. ;CENTER
• )CHILD CARE FOOD PROGRAM) 1 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 CENTERS CARE CENTER Johnstown Head Start Center
Letford Elementary School
3. NAME AND TITLE OF PERSON RESPONS:3LE AT CENTER
West Charlotte Street, Circle Drive
Mabel Tapia, Teacher Johnstown, CO 80534
TELEPHONE NUMBER:AC (303) 587-2888
IS THIS A PRIVATE ORGANIZATION?('PRIVATE" MEANS NON-GOVERNMENTAL) EA. IS CENTER LICENSED OR APPROVED BY FEDERAL,STATE,OR LOCAL AUTHORITY?
❑ YES ENO DYES ❑NO
(If"YES,"except for;-oprietcryTitle 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 IPS and cover letter which
indicates that an application has been(sled with IRS or documentation that center
participates in another Federal Program requiring nonprofit status.) N/A — Head Start
5A. DOES YOUR CENTER NOW PARTICIPATE CR H.AVE YOU PARTICIPATED 69. IF-NO- HAS INSTITUTION APPLIED TO LICENSING AUTHORITIES FOR LICENSING
IN PROGRAMS)FUNDED THROUGH THE FOOD AND NUTRITION OR APPROVAL?
SERVICE IN THE PAST THREE YEARS?
❑YES
YES (If"YES,-give name of program ❑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 cpph'cation.)
53. DOES CENTER PARTICIPATE IN THE HEAOSTART PROGRAM?
® YES ❑ 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.)
❑YES (Specify program) SC] NO
7.OPERATING DC,TA 8. MEAL SERVICE
A. HOURS OF OPERATION IN/I MEAL SERVED TIME OF MEAL SERVICES) K MEALS EXPECTED TO
FROM TO - BE SERVED
8:30 3:30 A. Cg BREAKFAST 8:30 20
B. NUMBER OF OPERATING DAYS C. NUMBER OF OPERATING WEEKS
PER.WEEK FIR YEAR 9. ❑ AM SUPPLEMENT
4 36 (less holidays)
D. ANNUAL DATES OF OPERATION �
STARTING ENDING C. cI LUNCH 11:30 20
September 19, 1985 May 31, 1986
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) lJV E. O SUPPER
June, July, August
10- NUMBER OF CHILDREN ENROLLED IN:
9. METHOD BY WHICH MEALS WILL BE PROVIDED(NCI A.FREE CATEGORY B.REDUCED PRICE CATEGORY
A. ❑ PREPARATION AT MEAL SERVICE LOCATION 20 •
B. ❑ PREPARATION AT CENTRAL KITCHEN C.NOT ELIGIBLE FOR FREE OR D.TOTAL NUMBER OF ENROLLED
REDUCED PRICE CATEGORY CHILDREN (A +B+C)
C. Sj UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM
D. ❑ UNDER CONTRACT WITH FOOD SEF VICE MANAGEMENT COMPANY 0 20
12. IS THIS A PRICING OR NON°RICING PROGRAM?(Check one)
'1.AGE RANGE OF ENROL:_ED CHILOREN ❑ PRICING ® NONPRICING
FROM 3z 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)
NUMBER OF PERSONNEL
NAME OF POSITION SPECIFIC CCFP FOOD SERVICE DUTIES IN THIS POSITION
(A) 151 IC)
Teacher Prepares snacks, helps children with serving 1
Teacher Aide • Prepares snacks , helps children with serving 1
•
FORM FNS-341 (7-B3) Precious editions are obsolete.
.c Ca';75> >_C:ES' /e►% 15.CENTER REOU ("Ni" one) ..
• •ADVANCE PAYSMENTS ❑ YES / ® NO EJ DONATED F'aIODS ❑ CASH INSTEAD OF
DONATED FOODS
,**PARTIAL ADVANCE O YES (If"YES"indicate amount E NO -NOTE:Approved centers which prefer cash instead of donated foods will receive such
• *PAYMENT 5 of advance payment per cash payments. Centers which choose donated foods may be required to accept cash
month) instead. Donated food or cash in lieu of food is provided in addition to CCFP
reimbursements.
'r-Ov.7.:E IS-'...17E OF THE RACIAL'ETHNIC MAKEUP OF THE?OPLJLATIG'.-3 BE SERVED,OESCRIBE EFFORTS TO BE USE01h1 TO ASSURE THAT MINORITY POPULATIONS
C'S TUNfTY TO PARTICIPATE,AND(21 TO CONTACT:!INORTY:.'.J GRASSROOTS ORGANIZATIONS ABOUT THE OPPORTUNITY TO PARTICIPATE IN THE
75 Hispanic
25 Anglo, please see the explanation under the Greeley Center,
•
•
•
•
•
•
•
' C..B"?TL THAT THE D FORMATION ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE;THAT I WILL ACCEPT FINAL ADMINISTRATIVE AND
'FISPA C?AL RE:?ON:IBILITY FOR TOTAL CHILD CARE FOOD PROGRAM O?ERATIONS AT THIS CENTER IF NOT UNDER A SPONSORING ORGANIZATION:THAT
^3 EE' `ENT WILL BE CLAIMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;AND THAT THE CCFP WILL.BE AVAILABLE TO ALL ELIGIBLE
: £_^,F REGARDLESS OP RACE,COLOR,NATIONAL ORIGIN,SEX, HANDICAP,OR AGE.
:NDE'P.STAND THAT THIS NTORMATION IS BEING GIVEN IN CONNECTION WITH THE RECEIPT OF FEDERAL FUNDS,AND THAT A DELIBERATE MISREPRE-
SENTATION MAY SL-BJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL CRIMINAL STATUTES.
• 17. SIGNATURES •
•,s Y 0 S'.TE= =E"i5.5.NTATIVE (Type or Print) NA.!E OF SPONSOR REPRESENTATIVE (If center will be sponsored. Type or Print,)
:1.anita Santana, Head Start Director
SIGNATURE OF CENTER REPRESENTATIVE DATE SIGNATURE OF SPONSORING ORGANIZATION REPRESENTATIVE
(If center will be sponsored)
FORM APPROVED OMB NO.0584-0055
• U.S.DEPART'.ENT OF AGRICULTU F000 AND NUTRITION SEa':ICE ' GREEMENT NUMBER
. APPLICATION FOR TICIPAT10N FOR r 1
' CHILD CAne CENTER
'ICHILD CARE FOOD PROGRAM) 08-65103
INSTRUCTIONS: Complete in duplicate.Type or print clearly. If a sponsored faciity, the original (r ad 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 sheetu if necessary.
- TYPE OF CENTER 2.NAVE AND ADDRESS 3 CENTER(If Mailing Address Different from Address of
Feed'r.g Location.P.ese Pct 4e both.Also include County.)
CHILD CARE 0 PROPRIETARY O OUTSIDE•SCHOOL•HOURS i
CENTER TITLE XX CENTERS CARE CENTER Pierce Head Start Center
United Methodist Church
NA'.1':AND TITLE OF PERSON RESPONS,3L£AT CENTER P. O. Box 250 (429 3rd Street)
Pierce, CO 83550 •
Ramona Lucero, Teacher
T£LEP-ONE NUMBER.sC (303) 834-1264
15 THIS A PRIVATE ORGANrZAT;O',?r PRIVATE"MEANS NON-GOVERNMENTALI 6A. IS =ENTER LICENSES Sr APPROVED BY FEDERAL STATE,OR LOCAL AUTHORITY?
0 YES (g NO 0 YES 0 NO
(If"YES."except for praprie'c:'Title XX Center,attach a copy of letter from IRS ' (If—YES."attach a top?of licensing or approval document)
documenting tax-exempt status or copy of application to IRS and corer 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. DOES YOUR CENTER NOW PARTICIPATE OR HAVE YOU PARTICIPATED 68. IF .NO' HAS INSTITLTioN APPLIED TO LICENSING AUTHORITIES FOR LICENSING
IN PROGRAMtSI FUNDED THROUGH THE FOOT)AND NUTRITION OR APPROVAL?
SERVICE IN THE PAST THREE YEARS?
❑YES
❑YES (if"YES,"give name of program 0 NO •
and dates of participcton) CCFP 5/80 t0 Present (If-YES."attach a copy of first page of application and corer letter or other
proof of application.)
B. DOES CENTER PARTICIPATE IN T-if.HEAOSTART PROGRAM?
❑YES ❑NO
❑NO
C. DOES CENTER PARTiCIPATE IN A IY OTHER FEOERALLY-FUNDED (If".VO'contact your FNS Regional Office.Not eligible to participate untE
PROGRAMS? sore form of Licenu'lgfiipprocal is obtained.)
❑YES (Specify program) ® NO
7.OPERATING DATA 8.MEAL SERVICE
A. HOURS OF OPERATION Iv'+ MEAL SERVED TIME OF MEAL SERV)CEIS) F MEALS EXPECTED TO
FROM TO OE SERVED
8:30 3:30 A. f BREAKFAST 9:00 30
B. NUMBER OF OPERATING DAYS C. NUMBER OF OPERATING WEEKS
PER WEEK PER YEAR B. C AM SUPPLEMENT
4_ 315 (less holidays)
0.ANNUAL DATES OF OPERATION
STARTING MING C. Z LUNCH 11:45 30
September 19, 1985 May 31, 1986
E. LIST ANY MONTHS DURING Wa:CH THE CHILD CARS FOOD PROGRAM 0. PM SUPPLEMENT 2:00 30
WILL NOT OPERATE(Irttude dates of elosMg and reopening)
ing)
E. 0 SUPPER
June, July, August 10.NUMBER OF CHILDREN ENROLLED IN:
i METHOD BY WHICH MEALS WILL BE PROVIDED IN/) A.FREE CATEGORY B.REDUCED PRICE CATEGORY
A. ® PREPARATION AT MEAL SERVICE LOCATION 30 0
B. 0 PREPARATION AT CENTRAL KITCHEN C.NOT E IG19LE FOR FREE OR D.TOTAL NUMBER OF ENROLLED
RED_ceo PRICE CATEGORY CHILDREN (A+B+C)
C. O UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM D. ❑ UNDER CONTRACT WITH FOOD SERVICE MANAGEMENT COMPANY 's3 30 •
12. IS 7-15 A PRICING OR NONPRICING PROGRAM?(Check one)
AGE RANGE OF ENROLLED c.d;LD=EN ❑ PRICING ❑NONPRICING
FROM 3%2 years old To 5 years old
13. FOOD SERVICE STAFFING PATTERN (Enter only personnel who will perform Child Care Food Program food Truce functions in this center)
NA.'1E OF POSITION SPECIFIC CCFP FOOD SERVICE DUTIES NUMBER OF PERSONNEL
LN THIS POSIITON
IA, IBI (C) .
Cook Cooks food and prepares breakfast and snack 1
Teacher Helps children with servinn 1
Teacher Aide Helps children with serving . 1
FORM FNS-341 .7-8 31 Precious editions are obsolete.
:ENTER REQUESTS !f,' 15 CENTER REly�TS;(••VJ•• one) •
ADVANCE PAYMENTS O YES T ❑ NO ECI DONATE,VVVD,,,FIOODS O CASH INSTEAD OF
DONATED FOODS
PARTIAL ADVANCE O YES (If"YES"indicate amount - E NO - NOTE:Approved centers which prefer cash Instead of donated foods will receiae IL.
PAYMENTS of advance payment per cash payments. Centers which choose donated foods may be required to accept vas.:
month) instead.Donated food or cash in lieu of food is prodded by addition to CCFP
'reimbursements.
ROVIOE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE POPU!ATU•.TO BE SERVED DESCRIBE EFFORTS TO BE USED'1Ill TO ASSURE THAT MINORITY POPULATIONS
-AVE EQUAL OPPORTUNITY TO PARTICIPATE,AND(2)TO CONTACT MI\OR:TY 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 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 SPONSORLNG ORGANIZATION;THAT
REIMBURSEMENT WILL BE CLALMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;AND THAT THE CCFP WILL BE AVAILABLE TO ALL ELIGIBLE
Cr' 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 CRLMD AL STATUTES.
17.SIGNATURES
.-rE OF CENTER REPRESENTATIVE (Typr or Print) NAVE OF SPONSOR REPRESENTATIVE (If center will be sponsored. Type or Print)
_.anita Santana, Head Start Director
SIGNATURE OF CENTER REPRESENTATIVE DATE SIGNATURE OF SPONSORING ORGANIZATION REPRESENTATIVE
(If center will be sponsored)
U.S.DEPARTV_NT OF AGRICULTURE-FOOD ANC)NUTRITION SERVICE 'AGREEMENT NUMBER
APPLICATION FORpVTICIPATION FOR erilh
CHILD CC ENTER
(CHILD CARE FOOD PROGRAM) 1 08-65103
:cSTReCTIONS: 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
_olicy statement,one copy of your proposed public release,and continuation sheets if necessary.
OF CENTER 2.NAVE AND AOORESS OF CENTER (if Mailing Address Different front Address of
Feeding Location,Pease include both.Also include Calmly.)
CHILD CARE ❑ PROPRIETARY ❑ OUTSIDE-SCHOOL-HOURS
CENTER TITLE XX CENTERS CARE CENTER Firestone Head Start Center
%L YS?ANO TITLE OF PERSON RESPONS13L E AT CENTER 478 1st Street
Firestone, CO 80520
Agnes Martinez, Teacher
TELEPHONE NUMBER:AC •
.5 T-:S A PRIVATE OROA',IZATtON?("PRIVATE" YEARS NONGOVERNMENTAL) 6A, is CENTER LICEfs.=O OR APPROVED BY FEDERAL STATE,OR LOCAL AUTHORITY?
_; YES ®NO O YES • 0 NO
'lf"YES,"except for p-op.-is:cryl?itle XX Cenwr,attach a copy of letter from IRS (If"YES."attach a copy of licensing or approval document) •
documenting tax.exemp:status or copy of cpo.tcation 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
iF OCES YOUR CENTER NOW PARTICIPATE OR HAVE YOU PARTICIPATED 6B. IF-NO-HAS INSTITLI ION APPLIED TO LICENSING AUTHORITIES FOR LICENSING
IN PROG.RAMISI FUNDED THROUGH THE FJOD AND NUTRITION OR APPROVAL?
SERVICE IN THE PAST THREE YEARS?
❑YES
Z YES (If"YES.-give name of program ❑NO .
and dates of partielpatlon)CC C P 5/80 to Present (If"YES.-attach a copy of first page of application and cover letter or other
proof of application.)
is. OCES CENTER PARTICIPATE IN THE HEADSTART PROGRAM?
7C YES ❑NO '
❑NO
._ :ES CENTER PARTICIPATE IN ANY OTHER FEDERALLY-FUNDED (If"NO-contact yo'S INS Regional Office,Not eligible to participate until
Pr?GRAMS? some form of LicensiagrApproval is obtained.)
YES (Specify program) ®NO
7.OPERATING DATA 8.MEAL SERVICE
A. -OURS OF OPERATION IN II VEAL SERVED TIME OF MEAL SERVICE(S) IMEA EXPECTED TO
FROM TO B'ESfev,D
8:30 - 3:30 A.51 BREAKFAST 8:30 20
B. NUMBER OF OPERATING DAYS C. tiUM3ER OF OPERATING WEEKS
. PER WEEK PER YEAR B. ❑ AM SUPPLEMENT
4 36 (less holidays) .
D. ANNUAL DATES OF OPERATION
STARTING ENDING c. S LUNCH 11:30 20
September 19., 1985 _ May 31, 1986 • D. E PM SUPPLEMENT 2:00 20
E. LIST ANY MONTHS DURING WHICH THE CHILD CARE FOOD PROGRAM
MLL NOT OPERATE(Include dates of ciosrng and reopening)
E. O SUPPER
June, July, August 10.NUMBER OF CHILDREN ENROLLED IN:
_--'OD BY WHICH•'EALS WILL BE PROVIDED W I A. FREE CATEGORY B.REDUCED PRICE CATEGORY
A, ] PREPARATION AT MEAL SERVICE LOCATION 20 0
3 ] PREPARATION AT CENTRAL KITCHEN C.NOT ELIO:9LE FOR FpE= OR D.TOTAL NUMBER OF ENROLLED
REDUCED PRICE CATEGORY CHILDREN (A+B+C)
• ❑ UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM
• UNDER CONTRACT WITH FOOD SERVICE MANAGEMENT COMPANY 0 r�20
12, IS THIS A PRICING OR NONPRICING PROGRAM?(Check one)
RANGE OF E':PDLL30 CHILDREN 0 PRICING In NONPRICING
= 32 years old TO 5 years old
'3. FOOD SERVICE STAFFING PATTERN(L-:'r only personnel who will perform Child Care Food Program food service functions in this center)
NUMBER OF
NAME IN THIS POSITION
OF POSITION SPECIFIC CCFP FOOD SERVICE DUTIES SITIO IV£L
N
(Al 151 ta
Teacher Helps with serving children & preparing snacks 1
Teacher Aide Helps with serving children & Preparing snacks 1
FORM FNS.341 17.2 31 Precious editions are o5:oiete.
14. CENTER REC_,ESTS I1"1 15. CENTER REOU 5:('V'One)
ADVANCE PAYMENTS ❑ YES EDNO ® DONATED ._"�IIDS O CASH INSTEAD OF
DONATED FOODS - -
PARTIAL ADVANCE O YES (If"YES"indicate amount NO NOTE:Approved centers which prefer cash instead of donated foods will lathe such
PAYMENTS of advance payment per •cash payments. Centers which choose donated foods may be.required to accept cash
month) instead. Donated food or cash in lieu of food is provided in addition to CCFP
-reimbursements.
IS. PROVIDE AN ESTIMATE OF THE RACIAL'ETHNIC MAKEUP OF THE POPULAT-O`.TO BE SERVED, DESCRIBE EFFORTS TO BE USEDIIII TO ASSURE THAT MINORITY POPULATIONS
HAVE EOUAL OPPORTUNITY TO PARTICIPATE,AND(21 TO CONTACT MINGR.-V AND GRASSROOTS ORGANIZATIONS ABOUT THE OPPORTUNITY TO PARTICIPATE IN THE
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 FLNAL.ADMINISTRATIVE AND
FINANCIAL RESPONSIBILITY FOR TOTAL CHILD CARE FOOD PROGRAM OPERATIONS AT THIS CENTER IF NOT UNDER A SPONSORING ORGANIZATION;THAT
RELMBURSEMENT RILL BE CLALMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;AND THAT THE CCFP WILL BE AVAILABLE TO ALL ELIGIBLE
CHILDREN REGARDLESS OF RACE,COLOR,NATIONAL ORIGIN,SEN. HANDICAP,OR AGE.
I UNDERSTAND THAT THIS LNFORMNnON 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 LENTS? RE'R ISENTATIVE (Type or Print) NA'.E OF SPONSOR REPRESENTATIVE (If center will be sponsored. Type or Print.)
Juanita Santana, Head Start Director
DATE SIGNATURE OF CENTER REPRESENTATIVE DATE SIGNATURE OF SPONSORING ORGANIZATION REPRESENTATIVE
- (If center will be sponsored)
Agreement No. 08-65103-00-0
NONDISCRIMINATION POLICY STATEMENT
FOR
THE CHILD CARE FOOD PROGRAM
The Weld County Board
1. of Commissioners 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 cf race, color, national origin, age, sex, or handicap, 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. / yj We have attached a copy of the public release and have indicated
to whom and when it was sent .
b. / / A copy of the news release that was published is attached.
(Please send the full newspaper page on which the release was
printed.)
c. 1--7 We have collected actual beneficiary data by racial/ethnic
category for each child presently enrolled, and have included
it as a part of the Nondiscrimination Policy Statement. The
institution understands that the collection of this information
is strictly for statistical reporting requirements and has no
effect on the determination of their eligibility to receive
benefits under the program.
Chairman 09/11/85
o Spon r Signature) (Title) (Date)
Jacqueline Johnson ,
FOR USDA ONLY ----
Approved by (Name) (Title) (Date)
(This form is not to be
used by FDCH sponsors.)
Racial/Ethni`1Makeup of Service Area and Enrollment
Describe your admission requirements:
Individuals must meet the eligihility criteria of the Head Start Program in order
to he admitted into the program
That membership requirements must children fulfill before being admitted to your
child care facility? (Explain)
There are nn membership requirements. Admission to Head Start is_ based on a
needs test and the requirement to meet federal guidelines ' eligibility criteria
Estimate racial/ethnic makeup of your service area: (approximate percentages)
,4% American Indian or Alaskan Native
.6% Asian or Pacific Islander
.5%
Black (not of Hispanic origin)
17% Hispanic
81% White (not of Hispanic origin)
Note: -Percentages are rounded and may not add to 100%
Racial/ethnic makeup of your enrollment: (approximate percentages)
.5% American Indian or Alaskan Native
0- Asian or Pacific Islander
.5% Black (not of Hispanic origin)
70% Hispanic
29% White (not of Hispanic origin)
Note: Percentages are rounded and may not add to 100%
Give names of all other Federal Agencies providing financial assistance.
Department of Health and Human Services - ACYF - Head Start Branch
Have you ever been found to be in noncompliance of the Civil Rights laws by any
Federal Agencies? / / Yes / X / No
(Ne)
acq� ohnsonam
Chairman, Board ofCounty Commissioners
(Title)
United Sta^es .Foocd Mountain 2420 West 26th Avenue
• j; Department of • Nutrition Plains Denver, CO 80211
l<4j Agriculture Service Region
Telephone No. _ (303) 353-0540 Agreement No. 08-651(13-00-0
CERTIFICATE OF AUTHORITY
This is to certify that
Executive Director (Speckman)
Walter J. Speckman OR Juanita Santana ,
Head Start Director (Santana)
(MANUAL SIGNATURE of Person to be Authorized) (Title)
is designated as the authorized representative of the
Weld County Government/
Weld County Division of Human
Resources' Head Start Program P.O. Box 1805 Greeley, Colorado 80632
(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 Government
(Name of Sponsoring Agency)
*SIGNATURE MUST BE DIFFERENT
FROM PERSON DESIGNATED AS :
AUTHORIZED REPRESENTATIVE SIG TUBE o fficial of Sponsoring
Agency)
Jacqueline Johnson
Chairman . Weld County Board of Commissioners
(Title of Official)
Date 09/11/85
Hello