HomeMy WebLinkAbout910507.tiff RESOLUTION
RE: APPROVE STATEMENT OF AUTHORITY TO STATE DEPARTMENT OF HEALTH CHILD AND
ADULT CARE FOOD PROGRAM AND AUTHORIZE CHAIRMAN TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado,
pursuant to Colorado statute and the Weld County Home Rule Charter, is vested
with the authority of administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Statement of Authority to be
submitted to the State Department of Health Child and Adult Care Food Program for
the Family Educational Network 1991 Summer Migrant Head Start Program, with the
further terms and conditions being as stated in said Statement of Authority, and
WHEREAS, after review, the Board deems it advisable to approve said
Statement of Authority, a copy of which is attached hereto and incorporated
herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Statement of Authority to be submitted to the State
Department of Health Child and Adult Care Food Program be, and hereby is,
approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is,
authorized to sign said Statement of Authority and Certificate of Authority.
The above and foregoing Resolution was, on motion duly made and seconded,
adopted by the following vote on the 10th day of June, A.D. , 1991.
/01e BOARD OF COUNTY COMMISSIONERS
ATTEST: J/ Z�� WELD COUNT , OLORADO
Weld County Clerk to the Board
Gor ac , irman
By: C '�/L --(79 i s T 2—•—
Deputy Clerk to the Boar Georr/ge Kenn dy, Pro-Tem '
APPROVED AS T FORM:
^� Constance L. Harbert
/\ 117,9 y
County Attorney C. W. Kirby
W. H. Web to
910507
' MEMORAnDum
IIIIk Gordon E. Lacy, Chairman
To Board of County Commissioners Date June 6, 1991
COLORADO From Walter J. Speckman, Executive Director, Human Resources
Subject: Child and Adult Care Food Program (CACFP) Application for FENWC
Migrant Head Start Program
Enclosed for Board approval is the application for food reimbursement
through the Child and Adult Care Food Program for the 1991 Summer
Migrant Head Start Program.
If you have any questions, telephone me at 353-3816.
910507
Hk oln
camcS t1ST FOR CH= CARE CENTER OR S2ONSCR
Return to: Agreement T nc‘ irSI 3
Child and Adult Care Food Program Canter or c-£ y H ` ) u1�e w
Colorado Department of Health Sponsor Name: ..c4-tt-wlo.,, vficzt u-,/cp
4210 East 11th Avenue
Denver, CO 80220 Amic.P` ,\ `\'"r � yLa �kA-ivoy1�
L-OcLd CA_)�-1,
I am returning to you the following completed forms for the Child and Adult
Care Food Program:
_ 3 EA Agreement CACFP 300
_ 1 . A Center Application for each center CACFP 301
_ 2 EA Nondiscrimination Policy Statement/Press Release CACFP 303N or
CACFP 3032
_ 2 EA Press Release (reverse side of Nondiscrimination Policy Statement)
_ 2 EA Donated Foods (Commodities) Addendum
_ 1 EA Certificate of Authority CACFP 100 - Statement of Author_t_r
CACFP 101
_ 1 ZA Pr=_award Compliance Review
_ Cony/Copies of current child care license(s) for each
center, or copy/copies of timely renewal receipts, if appropriate.
_ Copies of two weeks , menus for each meal or snack claimed.
_ Copies at _:C weeks ' infant menus, if applicable (ages Mirth to 1 _ye=ar) .
_ Copy of food service contract(s) , if applicable
1 EA Fourth Meal Memorandum (Policy Memo TCOH-90-o)
1 EA Audit Questionnaire
— 1 EA TAXPAYER IDENTIFICATION NUMBER FORM
FOR ?ROI= TIT= XX CENTERS =22
_ 2 Ea Agreement Addendum for :or Prot__ Title XX Canters
Copy of each contract with Department of Social Services for the car=_
of Title .i Children (Please sand all 4 pages. )
_ _ EA Roster of enrolled children with Title XX children designated.
A separate roster is required for each center.
SPONSOR ONLY
EA Sponsor Application CACFP 302
NEW CENTER OR NEW SPONSOR ONLY
_ (For Nonprofit new Centers or Sponsors only) : 1 Copy of Federal ERS Tax
Exemption letter (or, if moving toward tax exemption, a copy of the
cover letter and first page of the application sent to IRS)
�- 1 TAXPAYER IDENTIFICATION NUMBER FORD:
��e�� s199 /3 /
Signature o Administrator Date
or Alit:oriced Representative (1_05/11'1
C _ORADO DEPARTMENT OF HEALTK
CHILD AND ADULT CARE FOOD PROGRAM
STATEMENT OF AUTHORITY
(FOR PROFIT CENTERS, DO NOT COMPLETE THIS FORM)
CHECK CORRECT BOX:
❑ NONPROFIT ORGANIZATION
❑ CHURCH Agreement # 08 65103
I, (We), the undersigned, state that the below-named child care center(s) is an integral part of and
therefore under the direct control and supervision of the governing body of the
Weld County Division of Human Resources. Family Educational Network
(Name of the Organization or Church)
•
whose address is 520 13 Avenue Greeley 80631
_. (Street or Route) (City) (Zip Code)
( 303 856-0600 -
(Telephone Number)
and that all funds relating to the Child and Adult Care Food Program will be subject to the control of the
duly constituted governing body of the above-named organization or church and that all funds received
for the operation of the child care center's Child and Adult Care Food Program will be used exclusively for
the purpose for which they were received. The individual(s) whose name and signature appears on the
reverse side of this form, is authorized to sign the Agreement and all other official documents in connec-
tion with the Child & Adult Care Food Program.
Name of Child Care Center(s) Address of Child Care Center(s)
Greeley;'Migrant Head Start 520 13 Avenue, Greeley, CO 80631
Frederick, Migrant Head Start 340 Maple, Frederick, CU 80530
Brighton, Migrant Head Start 675 Egbert, Brighton, CO 80601 -
Fort Collins, Migrant Head Start Werner Elementary, 5400 Mail (,reek Rd. 80525
Fort Morgan, Migrant Head Start Baker Elementary, 300 Lake St. 80701
I (we) understand that the information on this form is being given in connection with the receipt of
Federal funds and that all of the provisions of the Agreement (form CACFP 300) apply.
Chairperson,
iX • Weld County Board of Commissioners
e of C ai o e Board of Directors Official Title
for Organiz n or Church
Cif-or n " ,- La y 6/10/91
r Na /� Date /
ATTEST: BY: ' "7,Ti(�T d1/ / /
/ U TY CLERK TO BOARD AND/OR DEPUTY CLERK TO THE BOARD
2 Executive Director
IgnaW /Of Pastor or Executive Director of Church Official Title
Walter J Speckman
Print Name Date
•
CACFP 101 (5/90) 1f0lyr''cl`l
.,QLORADO DEPARTMENT OF HEAL t
CHILD AND ADULT CARE FOOD PROGRAM
CERTIFICATE OF AUTHORITY
This is to erti Agreement # 08 65103
1. 2. /
Signature Signature
Wa r J. Speckman Tere Keller
Print Name Print Name
Fxerutive Director Director
Title Title
is the duly designated Authorized Representatives)for:
Family Educational Network of Weld County
Name of Center or Sponsor
MAILING ADDRESS:
(Your reimbursement check will be sent to this address.)
PO Box 1805
Street Address
Greeley Colorado 80632
City State Zip Code
( 303 )356-0600 -
Business Phone
The Authorized Representative(s) is fully-empowered to enter into any agreement with the Colorado
Department of Health Child and Adult Care Food Program and may act for the above-mentioned center
or sponsor in preparing and signing documents and reports pertaining to the management of the
Child and Adult Care Food Program.
SI NATURE BEHALF OF CHILD CARE CENTER OR SPONSOR
Chairperson,
• Weld County Board of Commissioners
=lure of w Center or Sponsor Official Title
[other than Aut zed Representative(s)] (Chair or President of Board, Executive
Director, or Owner)
Gordon E. Lacy (PhD /9I
Print Name Date
Return one copy to the Colorado Department of Health Child and Adult Care Food Program, and keep
one copy for your files.When there is a change of Authorized Representative it shall be the respon-
sibilityof the center or sponsor to request from this office forms to register the change.The signa-
ture of the Authorized Representative on the Claim for Reimbursement must match the signature on this
form or the Claim cannot be processed and your reimbursement will be delayed. It is to your benefit to
have two people designated as Authorized Representatives.
ATTEST aLe
WELD COUNTY CLERK TO THE BOARD
BY: l fA� r� i�4Ql�
DEPUTY CI Eni ro '1'P," "In^,
CACFP 100 (5/90) 91059'7
t...,LORADO DEPARTMENT OF HEALTh
CHILD AND ADULT CARE FOOD PROGRAM
CERTIFICATE OF AUTHORITY
A reement # 08 65103
This is to ce t th 9
,. rU,L z. /-&t4 ,(�� ��.�
Signature f Signature
TPrP Kell pr
Print Name Print Name
Executive Director Director
Title Title .
•
is the duly designated Authorized Representative(s) for:
Family Educational Network of Weld County
Name of Center or Sponsor
MAILING ADDRESS:
(Your reimbursement check will be sent to this address.)
PO Box 1805
Street Address
GrPP1 Py, Cnlnra do 80632
City State Zip Code
( 303 ) 356-0600 -
Business Phone
The Authorized Representative(s) is fully-empowered to enter into any agreement with the Colorado
Department of Health Child and Adult Care Food Program and may act for the above-mentioned center
or sponsor in preparing and signing documents and reports pertaining to the management of the
Child and Adult Care Food Program.
SIG T RE ON BEHALF OF CHILD CARE CENTER OR SPONSOR
p Chairperson,
Weld County Board of Commissioners
si ure o i of Center or Sponsor Official Title
[other than Aut ized Representative(s)] (Chair or President of Board, Executive
Director, or Owner)
Gordon E . Lacy (Mt)M/
Print Name Date
Return one copy to the Colorado Department of Health Child and Adult Care Food Program, and keep
one copy for your files.When there is a change of Authorized Representative it shall be the respon-
sibility of the center or sponsor to request from this office forms to register the change.The signa-
ture of the Authorized Representative on the Claim for Reimbursement must match the signature on this
form or the Claim cannot be processed and your reimbursement will be delayed. It is to your benefit to
have two people designated as Authorized Representatives.
ATTEST: Wallin
WELD COUNTY CLE K T THE BOARD
BY. DEPUTY CLERK 0 THE BOARD
910507
CACFP 100 (5/90)
uuLORADO DEPARTMENT OF HEALTH .
CHILD AND ADULT CARE FOOD PROGRAM
STATEMENT OF AUTHORITY
(FOR PROFIT CENTERS, DO NOT COMPLETE THIS FORM)
CHECK CORRECT BOX:
I NONPROFIT ORGANIZATION Agreement # 08 65103
❑ CHURCH
I, (We), the undersigned, state that the below-named child care center(s) is an integral part of and
therefore under the direct control and supervision of the governing body of the
Wald Cnunty Division of Human Rosen: ac Family Fdurational Nptwnrk —,
(Name of the Organization or Church)
whose address is 520 13 Avenue Greeley 8n631
(Street or Route) (City) (Zip Code)
(103 ) 3c6-0600
(Telephone Number)
and that all funds relating to the Child and Adult Care Food Program will be subject to the control of the
duly constituted governing body of the above-named organization or church and that all funds received
for the operation of the child care center's Child and Adult Care Food Program will be used exclusively for
the purpose for which they were received. The individual(s) whose name and signature appears on the
reverse side of this form, is authorized to sign the Agreement and all other official documents in connec-
tion with the Child & Adult Care Food Program.
Name of Child Care Center(s) Address of Child Care Center(s)
Greeley, Migrant Head Start 520 13 Avenue. Greeley, en 8n631
Frederick, Migrant Head Start 340 Maple. Frederick. CO aim()
Brighton. Migrant Head Start 675 Fghert. Brighton, rn Rn6n1 .
Fort Collins, Migrant Head Start Werner Elementary, 5400 Mail Creek Rd. 80525
Fort Morgan, Migrant Head Start Baker Elementary, 300 Lake St. , 80701
I (we) understand that the information on this form is being given in connection with the receipt of
Federal funds and that all of the provisions of the Agreement (form CACFP 300) apply.
1 Chairperson, Weld County Board of Commissioner
Sig re of air a Board of Directors Official Title
for Organi ion or Church
6/10/91
Pri t N e Date 9
ATTEST: ' /�i't�����yO�'✓/
AND/OR BY:
W T L RD DEPUTY CLERK TO THE BOARD
z.
Executive Director
'gnat <-of Pastor or Executive Director of Church Official Title
Walter J. S eckman
Print Name Date
CACFP 101 (5/90) StOriifr
COLORADO DEPARTMENT OF HEALTH
CHILD AND ADULT CARE FOOD PROGRAM
PREAWARD COMPLIANCE REVIEW
Center or Sponsor Name: Fami ly Educational Network of Weld Agreement # OR nsi n3
County
The Colorado Department of Health,Child&Adult Care Food Program,is required to conduct a preaward civil rights com-
pliance review of centers or sponsors applying for CACFP participation. Please complete the following information.
1. ESTIMATE the racial/ethnic makeup of the population of the area to be served(approximate percentages).Sponsor
must combine this information for all centers. Usually this information can be obtained from the local school dis-
trict, Chamber of Commerce, Census Bureau, or Public Library.
3% American Indian or Alaskan Native 95% Hispanic (a person of Mexican, Puerto Rican, Cuban,
Central or South American,or other Spanish culture or
Asian or Pacific Islander origin, regardless of race)
0
Black(not of Hispanic origin) 26 White (not of Hispanic origin)
2. "COUNT the actual number of children by racial/ethnic makeup in your center(s)and indicate those figures here.
Sponsor must combine for all centers.
3% American Indian or Alaskan Native q5% Hispanic (a person of Mexican, Puerto Rican, Cuban,
Central or South American,or other Spanish culture or
Asian or Pacific Islander origin, regardless of race)
Black(not of Hispanic origin) 2% White (not of Hispanic origin)
3. What efforts will be used to assure that minority populations&grassroots organizations have an equal opportunity to
participate or are informed about changes in the Program?
_X Distribution of brochures of Program information at public locations
X— Public service announcements in local newspaper, on radio, or on television (circle media type used)
Paid advertisements in local newspapers
X Other. Please explain: Agency referrals
Did the items you checked above include the following nondiscrimination statement?Yes_Xr No
USDA forbids discrimination because of race,color,national origin,age,sex,or handicap.Any person who believes he
or she has been discriminated against in any USDA-related activity should write immediately to the Secretary of
Agriculture,Washington, D.C. 20250.
4. Is membership in a specific organization required before children can be enrolled? Yes_ No X
If yes, please explain:
5. Have you ever been found to be in noncompliance of the Civil Rights laws by any federal agency?
Yes_ No X If yes, please explain:
*Visual identification may be used by centers or sponsor to determine the child's racial/ethnic category.A child may be included
in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging. Parents/
Guardians may be asked to identify the racial/ethnic group of their own child only after it has been explained,and they under-
stand 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.As new children are enrolled,you will need to deter-
mine their racial/ethnic background and keep this information in a confidential place.
pectic.,
SIGNATURE OF AD NISTRATOR OR AUTHORIZED REPRESENTATIVE DATE
91.0 Cri
CACFP 102 (5/90)
COLORADO DEPARTMENT OF HEALTH Agreement Number d4 6000814
CHILD & ADULT CARE FOOD PROGRAM
Family Educational Network of Weld County
AGREEMENT FOR CHILD CARE CENTER OR Name of Center or Sponsor
SPONSOR OF CHILD CARE CENTERS
In order to carry out the purpose of Section 17 of the National School a Collect family size and income information on the Income
Lunch Act, as amended, and the Regulations governing the Child & Eligibility Form(IEF)for children enrolled at all the centers listed
Adult Care Food Program(CACFP)issued thereunder(7 CFR Part 226) on Schedule A to determine which children are from families
the Colorado Department of Health(hereinafter referred to as the State meeting the income eligibility guidelines for free or reduced
Agency),and the Center or Sponsor,whose name and address appear meals.Children for whom family size and income information is
above, agree as follows: not available shall be reported under the paid (not eligible for
free or reduced meals) category only. An IEF is valid for 12
THE STATE AGENCY AGREES THAT: months from the date the center or sponsor approves it.
Meals may be claimed for reimbursement beginning with
To the extent of funds available,-it shall reimburse the institution for that date. It is never retroactive from the approval data.
creditable meals served to eligible children at child care centers listed Meals claimed after the expiration data can only be
on Schedule A attached hereto, during the effective period of this claimed in the paid category.
Agreement.During any fiscal year,the amount of reimbursement paid to
the center or sponsor shall be based on actual count of meals served by d. Claim reimbursement only for meals served to eligible enrolled
eligibility category. children in each income category within the limits of the license
or registration certificate.No more than 2 meals and 1 snack per
child shall be claimed.However,if a child is in care over 8 hours,
THE CENTER OR SPONSOR AGREES THAT: then an additional meal or snack may be claimed per child.In
this case,sign-in/sign-out sheets must be kept for all children
1. It will comply with Title VI of the Civil Rights Act of 1964(P.L. 88- claimed on the CACFP.
352) and all requirements imposed by the regulations of the
Department of Agriculture(7 CFR Part 15), Department of Justice e. Submit Claims for Reimbursement in accordance with pro-
(28 CFR Parts 42 and 50),and FNS directives or regulations issued cedures established by the State Agency. Claims that are
pursuant to that Act and the regulations,to the effect that,no per- received by the State Agency after noon on the 10th of the
son in the United States shall, on the ground of race,color, sex, month shall be processed for payment the following month.Only
national origin or ancestry,age,or handicap,be excluded from par- final claims received within 60 days following the close of the
ticipation in,be denied the benefits of,or be otherwise subject to claim month shall be eligible for reimbursement.
discrimination under any program or activity for which the institu-
tion receives Federal financial assistance from the State Agency f. Store, prepare,and serve food in conformance with all applic-
and hereby gives assurance that it will immediately take any able State and local health laws and regulations.
measures necessary to effectuate this Agreement.This assurance
is given in consideration of and for the purpose of obtaining any and g. Use cash-received-in-lieu-of commodities for the purchase of
all Federal financial assistance,grants,and loans of Federal funds, food.
reimbursable expenditures,grant or donations of Federal property.
By accepting this assurance,the institution agrees to compile data, r h. Maintain full and accurate records of the Pro
maintain records,and submit reports as required,to permit effec• gam, and
tive enforcement of Title VI and permit authorization personnel dur- retain such records for a period of three years and four
ing normal working hours to review such records, books, and months after the end of the fiscal year to which they
accounts as needed to ascertain compliance with Title VI.If there pertain.
are any violations of this assurance,the Department of Agriculture,
Food and Nutrition Service,or the State Agency,shall have the right i. Make all accounts and records pertaining to the Program avail-
to seek judicial enforcement of this assurance.This assurance is able to the State Agency and to USDA for audit or review at a
binding on the center or sponsor,its successors,transferees,and reasonable time and place.
assignees as long as it receives assistance or retains possession of
any assistance from the State Agency. j. Provide adequate supervisory and operational personnel for _
overall monitoring and management of each food service opera-
2. The governing body is responsible for the administration of the tion, and to promptly take such actions that are necessary to
centers listed on Schedule A of this Agreement,or it is an agency to correct deficiencies found at the time of any onsite visit,review,
which the centers listed on Schedule A have delegated authority or audit.
for the operation of the food service program.
k If a sponsor, monitor all centers at least 3 times each year,
3. In order to qualify for reimbursement under this Agreement,it shall including once during the first 6 weeks of CACFP operation.
conduct the Program in accordance with regulations governing the These reviews cannot be more than 6 months apart.All outside-
Child & Adult Care Food Program (7 CFR Part 226), appropriate school-hours centers must be monitored at least 6 times each
OMB circulars, State regulations, State Agency policies, and year,including once during the first month of CACFP operation.
specifically,shall conform to the following requirements: These reviews cannot be more than 3 months apart.
a Operate a nonprofit food service using all of the income solely 4. It Is a public organization or a nonprofit organization which has tax
for the operation or improvement of such service. exempt status such as under section 501(a) of the Internal
Revenue Code of 1954,or is moving toward compliance with the
b. Serve meals which meet the minimum nutritional requirements requirements of the aforementioned section in accordance with
specified in Schedule B of this Agreement. Section 226.16 of the Program regulations.
-or-
Serve the same meal at no separate charge from tuition to If a For Profit Title XX center,it certifies that it receives funds under
enrolled children who are in attendance at meal time(non- Title XX of the Social Security Act for at least 25 percent of each
pricing institution) and so designate on Application Form center's enrolled children during the month preceding application
and Nondiscrimination Policy Statement and abide by the to or renewal of the Program and shall continue to certify such infor-
terms of the Nondiscrimination Policy Statement and Pro- mation in each succeeding month.The institution shall not claim
gram Verification Rules (Regulations 226.23 h.l), reimbursement for meals served in any For Profit center for any
-or- month during which the center receives Title XX funds for less than
Have an identifiable separate charge from tuition for meals 25 percent of its enrolled children.
served to enrolled children (pricing institution) and so
designate on Application Form and Nondiscrimination 5. All child care centers listed on Schedule A have a valid license or
Policy Statement and abide by the terms of the Nondis- registration certificate for providing child care.
crimination Policy Statement and Program Verification
Rules (Regulations 226.23 h.2). 6. It provides organized child care in nonresidential situations.
..
CACFP 300(5/90) PAGE ONE
7. It accepts final financial and administrative responsibility for total The Agreement may be terminated upon ten(10)days written notice on
CACFP operations for each child care center under its juris• the part of either party hereto,and the State Agency may terminate this
diction. Agreement immediately after receipt of evidence that the terms and
conditions of this Agreement and of the regulations governing the Pro-
8. It will annually make available to the local media serving the area gram have not been fully complied with by the center or sponsor.Any
from which the center or sponsor draws its attendance, a public termination of this Agreement by the State Agency shall be in accord
release announcing the availability of meals to all eligible enrolled with applicable laws and regulations(Federal Regulations 226.6 10c).
children without regard to race, color, sex, national origin, age, No termination or expiration of this Agreement,however,shall affect the
or handicap. obligation of the center or sponsor to maintain and retain records and to
make such records available for audit.A center or sponsor may appeal a
termination according to procedures outlined in 7 CFR Part 226.
9. It understands and agrees that any materials developed with Pro-
gram funds by the center or sponsor may be freely reproduced,pro-
duced,or otherwise used by the USDA Food and Nutrition Service, The terms of this Agreement shall not be modified or changed in any
the Colorado Department of Health,or by other institutions under way other than by the consent in writing of both parties hereto.
the Child 8 Adult Care Food Program.
RECORDKEEPING REQUIREMENTS
THE STATE AGENCY AND CENTER OR SPONSOR MUTUALLY The center or sponsor must keep full and accurate records pertaining to
AGREE THAT: its food service as a basis for the Claim for Reimbursement and for audit
and review purposes. The records to be kept include the following:
1. Schedule A,listing centers approved for participation and meals to
be claimed for reimbursement,shall be a part of this Agreement. 1. Menus and food production records indicating quantities of foods
Centers or meals may added deleted from Schedule A prepared, number of persons prepared for,and serving sizes.The
as the need arises. All such changes must be confirmed in food production record must include the number of adults
writing and sent to the State Agency. All such references to served.
Schedule A shall be-deemed to include such Schedule as sup-
plemented and amended.
2. Daily record of meals served to children broken down by name by
2. The State Agency shall notify the center or sponsor of any change type of meal (breakfast, lunch, supper, or snack) and by income
in the minimum meal requirements or in the applicable rates of category •free, reduced,or paid (Record of Meals Served form).
reimbursement as soon as possible after notification from USDA.
3. Approved Income Eligibility Forms for enrolled children categorized
3. The center or sponsor may contract with a local school food as free or reduced.
authority or with a food service management company for the prep-
aration and delivery of meals or meal components.The center or 4. Documentation of income to the food service operation from funds
sponsor shall remain responsible for fulfillment of the terms of the to subsidize food service program,from State Agency CACFP reim-
Agreement.The center or sponsor must submit a copy of this con- bursement,from payments for adult meals and from all other sour-
tract to the State Agency. ces, including loans and donations to the food service program.
4. For the purposes of this Agreement the following-terms shall 5. Invoices or receipts from food service operation purchases includ-
mean, respectively: ing bills from food service management companies,payroll records
including fringe benefits,equipment costs,maintenance and repair
fees,office costs, utilities costs and other administrative costs.
DEFINITIONS
"Children" means(a)persons up to their 13th birthday and under, This documentation shall ensure that all reimbursement funds are
(b)children of migrant workers 15 years of age and under,and(c) used:(1)solely for the conduct of the food service,or(2)to improve
mentally or physically handicapped persons, as defined by the such food service operations principally for the benefit of the
State Agency,enrolled in an institution or child care facility serving enrolled children.DOCUMENTATION OF ALL COSTS PERTAIN•
a majority of persons 18 years of age and under. ING TO THE OPERATION OF THE CACFP MUST BE SPECIFIC-
ALLY ITEMIZED. DOCUMENTATION MUST CLEARLY SHOW
THAT THE FOOD SERVICE IS NONPROFIT BASED ON ALL
"Enrolled child"means a child whose parent or guardian has sub-
mitted to the center or sponsor a signed document which indicates CACFP INCOME AND EXPENSES.
that the child is enrolled for child care.
6. License, registration, or certification documentation
"Milk" means pasteurized fluid types of unflavored or flavored
whole milk,lowfat milk,skim milk,or cultured buttermilk which meet 7. Documentation of visits to child care centers to monitor com-
State and local standards for such milk except that,in the meal pat- pliance.This requirement pertains only to sponsors who administer
tern for infants(0 to 1 year of age),"milk"means unflavored types of more than one child care center in accordance with Federal
whole fluid milk or an equivalent quantity of reconstituted Regulation 228.16(d).
evaporated milk which meets such standards.All milk should con-
tain vitamins A and D at levels specified by the Food and Drug 8. Documentation of enrollment
Administration and be consistent with State and local standards for
such milk. 9. Documentation of attendance (rollbooks or sign in/sign out
sheets)
"Verification" means a review of the information reported by the
center or sponsor to the State Agency regarding the eligiblity of 1O. Documentation of Civil Rights racial/ethnic data
enrolled children for free or reduced meals.
•
11. Documentation of staff training pertaining to CACFP
This Agreement shall be effective with respect to meals served
during the period commencing the 1st day of October 1990 and 12. Copy of press release sent annually to the media
ending September 30, 1992 unless terminated earlier as herein
provided.The State Agency may renew this Agreement, by notice in 13. Special Diet Statement or Special Diet Statement for Handicapped
writing given to the center or sponsor,for such period as funds are avail- Child documenting variances from the CACFP meal patterns.
able for carrying out the Program.The State Agency Agreement to reim-
burse the center or sponsor is conditioned upon the continued
availability of funds appropriated for Child&Adult Care Food Program in 14. Food service management company contract or other food
a sufficient amount,and no legal liability on the part of the Government service contracts.
for the payment of any money shall arise unless and until such appropri-
ation shall have been provided. 15. All Department of Social Services contract(s) - For Profit Title XX
centers only.
16. Record of payment and billing forms from Department of Social
Services - For Profit Title XX centers only
17. Record of deposit of CACFP reimbursement
PAGE TWO
PION
C -,
v ,_
SCHEDULE A
Fill in the name and address of centers participating in the Child 8 Adult Care Food Program.
(Attach additional sheets it necessary.)
HOURS AND TYPE OF MEALS SERVED
TYPE OF No more than 2 meals and t snack per child
shall be claimed.
CENTER
DEPARTMENT OF However, it a child is in care over 8 hours, then an
SOCIAL SERVICES additional meal or snack may be claimed per child.
NAME AND ADDRESS c Child Care Center
H Head Start LICENSE
OF CENTER p. Outside School
%ours NUMBER BREAK- AM PM
ForProFAST SNACK LUNCH SNACK SUPPER
Greeley, Migrant Head H 58236 7:30 11-11:30 3:00
Start
520 13 Avenue
Greeley, CO 80631
Frederick, Migrant Head H 66816 7:30 11-11:30 3:00
Start
341 Maple,
Frederick, CO 80530
Brighton, Migrant Head H pending see 7:30 11-11:3) 3:00
Start attached
675 Egbert
Brighton, CO 80601
Fort Collins, Migrant H pending see 7:30 11-11:3D 3:00
Head Start attached
hJerner Elementary School
5400 Mail Creek Rd.
Fort Collins, CO 80525
Fort Morgan, Migrant H pending 8:00 11:30 2:30
Head Start
Baker Elementary School
300 Lake St.
Fort Morgan, CO 80701
91.050-1
PAGE THREE
SCHEDULE B
Requirements for Meals — Child & Adult Care Food Program
Each institution participating in the Program shall serve one or more of (2) Lunch or supper-1/2 cup of milk;1 ounce(edible portion as
the following types of meals,as provided in its approved application:(1) served)of lean meat,poultry,or fish,or 1 ounce of cheese,or
Breakfast, (2) Lunch, (3) Supper, (4) Snacks served between such 1 egg,or 1/4 cup of cooked dry beans or peas; or 2 table-
other meals. spoons of peanut butter; 1/4 cup of vegetables or fruits or
both consisting of two or more kinds; 1/2 slice of bread or
1. Except as otherwise provided in this section.and in any appendix to bread alternate, or 1/4 cup of cooked enriched or whole-
this part, each meal shall contain, as a minimum, the food com- grain rice, macaroni, noodles,or other pasta products.
ponents as follows:
a. A breakfast shall contain: (3) Snack—select two of the following four components-1/2
cup of milk; 1/2 ounce of meat or meat alternate (which
(1) A serving of fluid milk as a beverage,or on cereal,or used in includes 2 ounces or 1/4 cup of yogurt); 1/2 cup of juice,or
part for each purpose. equivalent quantity of fruit,or vegetables; 1/2 slice of bread
or bread alternate, or 1/4 cup (volume) or 1/3 ounces
(2) A serving of vegetable(s)or fruit or full-strength vegetable or (weight),whichever is less,of cereal,or 1/4 cup of cooked
fruit juice, or an equivalent quantity of any combination of enriched or whole-grain rice, macaroni, noodles or other
paste products.
these foods.
(3) A serving of whole-grain or enriched bread;or an equivalent b. Age 3 up to 6:
serving of cornbread,biscuits,rolls,muffins,etc.,made with (1) Breakfast-3/4 cup of milk, 1/2 cup of juice or fruit or
whole-grain or enriched meal or flour;or a serving of whole- vegetables;1/2 slice of bread or bread alternate,or 1/3 cup
grain or enriched or fortified cereal;or a serving of cooked (volume)or 1/2 ounce(weight),whichever is less of cereal or
whole-grain or enriched pasta or noodle products such as an equivalent quantity of both bread and cereal.
macaroni,or cereal grains such as rice,bulgur,or corn grits; -
or an equivalent quantity of any combination of any of
these foods. (2) Lunch or supper-3/4 cup milk,1 1 or
ounces(edible por-
tion as served)of lean meat,poultry,or fish,or 1 1/2 ounces of cheese,or 1 egg,or 3/8 cup of cooked dry beans or peas,
b. Both lunch and supper shall contain: or 3 tablespoons of peanut butter; 1/2 cup of vegetables or
(1) A serving of fluid milk as a beverage. fruits or both consisting of two or more kinds. 1/2 slice of
bread or bread alternate,or 1/4 cup of cooked enriched or
(2) A serving of lean meat,poultry or fish;or cheese;or an egg;or whole-grain rice, macaroni, noodles or other pasta
cooked dry beans or peas; or nuts or nut butters; or an products.
equivalent quantity of any combination of these foods.These
foods must be served in a main dish,or in a main dish and one (3) Snack—select two of the following components-1/2 cup of
other menu item,to meet this requirement.Cooked dry beans milk; 1/2 ounce of meat or meat alternate(which includes 2
or dry peas may be used as the meat alternate or as part of the ounces or 1/4 cup of yogurt); 1/2 cup of juice or an
vegetable/fruit component,but not as both food components equivalent quantity of fruit or vegetables; 1/2 slice of bread
in the same meal. or bread alternate;or 1/3 cup(volume)or 1/2 ounce(weight),
whichever is less,of cereal,or 1/4 cup of cooked enriched or
(3) A serving of two or more vegetables or fruits,or a combination whole-grain rice, macaroni,noodles,or other pasta products.
of both.Full-strength vegetable or fruit juice may be counted
to meet not more than one-half of this requirement. c. Age 6 through 12
(1) Breakfast-1 cup of milk; 1/2 cup of juice or fruit or
(4) A serving of whole-grain or enriched bread; or an equivalent vegetables; 1 slice of bread or bread alternate, or 3/4 cup
serving of cornbread, biscuits, rolls, muffins, etc., made of (volume)or 1 ounce(weight),whichever is less,of cereal or
whole-grain or enriched meal or flour;or a serving of cooked equivalent quantity of both bread and cereal.
whole-grain or enriched pasta or noodle products such as
macaroni,or cereal grains such as rice,bulgur,or corn grits;or (2) Lunch or supper-1 cup of milk;2 ounces(edible portion as
an equivalent quantity of any combination of these foods. served)of lean meat,poultry,or fish,or 2 ounces of cheese
or 1 egg,or 1/2 cup of cooked dry beans or peas,or 4 table-
t. Snack shall be served between other meal types and contain two spoons of peanut butter; 3/4 cup of vegetables or fruits or
of the following four components: both consisting of two or more kinds; 1 slice of bread or
(1) A serving of fluid milk as a beverage,or on cereal,or used in bread alternate, or 1/2 cup of cooked enriched or whole-
part for each purpose. grain rice, macaroni, noodles or other pasta products.
(2) A serving of meat or meat alternate. (3) Snack—select two of the following four components-1 cup
of milk;1 ounce of meat or meat alternate(which includes 4
(3) A serving of vegetable(s)orfruit(s)or full-strength vegetable ounces or 1/2 cup of yogurt);3/4 juice or equivalent quantity
or fruit juice,or an equivalent quantity of any combination of of fruit or vegetables; 1 slice of bread or bread altemate,or
of
these foods.Juice may not be served when milk is served as cereal
cup(volume) or 1 ounce(weight),whichever is less,
the only other component. cereal o 1/2 cup of cooked, enriched whole-grain rice,
macaroni, noodles or other pasta products.
(4) A serving of whole-grain or enriched bread;or an equivalent d. Age 12 and over:Adult-sized portions based on the greater food
serving of cornbread,biscuits,rolls,muffins,etc. made with needs of older boys and girls.
whole-grain or enriched meal or flour;or a serving of whole-
grain or enriched or fortified cereal;or a serving of cooked e. Infant meal patterns:
whole-grain or enriched pasta or noodle products such as
macaroni,or cereal grains such as rice,bulgur,or corn grits; (1) 0 through 3 months;
or an equivalent quantity of any combination of these
foods. (a) Breakfast-4.6 fluid ounces of iron-fortified infant
formula.
2. Except as otherwise provided in this section the minimum amounts
of component foods to serve at meals as set forth in subparagraphs (b) Lunch or supper-4-6 fluid ounces of iron-fortified
(b) (1), (2), and (3) of this section are as follows: infant formula.
a. Age 1 up to 3;
(c) Snack-4.6 fluid ounces of iron-fortified infant formula
(1) Breakfast-1/2 cup of milk, 1/4 cup of juice or fruit or
vegetables.1/2 slice of bread or bread alternate,or 1/4 cup (2) 4 through 7 months;
(volume)or 1/3 ounce(weight),whichever is less,of cereal or (a) Breakfast-4-8 fluid ounces of iron-fortified infant lor-
an equivalent quantity of both bread and cereal. mule, 0-3 tablespoons of iron-fk.rtified dry infant cereal
(optional).
PAGE FOUR
(b) Lunch or supper-4-8 fluid ounces of iron-fortified infant
a. Breakfast:
formula; 0-3 tablespoons of iron-fortified dry infant
cereal(optional);0-3 tablespoons of fruit or vegetable of (1) Include as often as practical an egg, or a 1-ounce serving
appropriate consistency or a combination of both (edible portion as served)of meat,poultry or fish;or 1 ounce
(optional). of cheese; or 2 tablespoons of peanut butter or an
equivalent quantity of any combination of these foods.
(c) Snack-4-6 fluid ounces of iron-fortified infant formula. (2) Additional foods may be served as desired.
(3) 8 months up to the first birthday; b. Lunch or supper: Additional foods may be served as desired.
(a) Breakfast-6-8 fluid ounces of iron-fortified infant fomula
or 6-8 fluid ounces of whole milk;2-4 tablespoons of iron- c. Snack: Include as often as practical a serving of meat or alter-
fortified dry infant cereal; 1-4 tablespoons of fruit or nate such as peanut butter or cheese or other foods needed to
vegetable of appropriate consistency or a combination of satisfy appetites.
both.
5. If emergency conditions prevent an institution normally having a
(b) Lunch or supper-6-8 fluid ounces of iron-fortified infant supply of milk from temporarily obtaining delivery thereof,the State
formula,or 6-8 fluid ounces whole milk;2-4 tablespoons agency,may approve the service of breakfasts,lunches,or suppers
of iron-fortified dry infant cereal and/or 1-4 tablespoons without milk during the emergency period.
of meat, fish, poultry, egg yolk or cooked dry beans or
peas,or 1/2.2 ounces(weight)of cheese or 1-4 ounces 6. Substitutions may be made in food listed in paragraphs(b),(1),(2),
(weight or volume)of cottage cheese or cheese food or and(3)of this section if individual participating children are unable,
cheese spread of appropriate consistency; and 1-4 because of medical or other special dietary needs, to consume
tablespoons of fruit or vegetable of appropriate consis- such foods.Such substitutions shall be made only when supported
tency or a combination of both. by a statement from a recognized medical authority which includes
recommended alternate foods.
(c) Snack-2-4 fluid ounces of iron-fortified infant formula,
whole fluid milk or full-strength fruit juice,0-1/2 slice of
crusty enriched or wholegrain bread (optional), or 0-2 STATE AGENCY AND CENTER OR SPONSOR FURTHER
cracker-type products(optional)made from whole grain AGREE THAT:
or enriched meal or flour and which are suitable for an
infant for use as a finger food. The center or sponsor shall accept full responsibility for providing
proper accountability,storage,and use of USDA commodity foods and
Breast milk,provided by the infant's mother,may be served in place of in so doing,shall promptly provide awritten response to claims that mis-
inf ant formula from birth through 11 months of age. However, meals handlings, diversions, and/or losses resulting from improper use or
containing only breast milk do not qualify for reimbursement. Meals storage have occurred.
containing breast milk served to infants 4 months of age or older may be
claimed for reimbursement when the other required meal component or components are supplied by the child care facility. The center or sponsor shall use USDA commodity foods received under
this Agreement solely for the benefit of those persons served or assist-
ed hall ot ise 3. For the purpose of this section, a cup means a standard mea-
commodityfoods without prior written t en napproval o dispose
the center or sponsor and of theS DA
State Agency.
suring cup.
4. To improve the nutrition of participating children additional foods
may be served with each meai as follows:
SIGNATURE ON BEHALF OF CENTER OR SPONSOR
I certify that the information on this form is true and correct to the best of my knowledge.I understand that this information is being given in con-
nection with the receipt of Federal funds, and that deliberate misrepresentation may subject me to prosecution under applicable State and
Federal criminal statutes.
Signature
Tere Keller Ilra ;,1e Date
Print Name
Please complete, sign,and return all 3 copies to the Colorado Department of Health Child 8 Adult Care Food Program.
SIGNATURES ON
&BEHALF
OF CARE OD PROGRAM COLORADO DEPARTMENT OF HEALTH
CHILD For the Executive Director.Colorado Debarment of Health
Date
Administrator,CACFP
Title Date
TO BE FILLED OUT BY COLORADO DEPARTMENT OF HEALTH, Center or Sponsor will receive for its child care centers. Head
CHILD 8 ADULT CARE FOOD PROGRAM: St rt Centers. outside school-hours centers, or For Profit Title
❑ Regular Donated Commodities
OR
❑ Cash-in-lieu of Commodities(with bonus commodities)
PAGE FIVE 0 0�_,�
Y iJ
COLORADO DEPARTMENT OF HEALTH Agreement Number: d4 6000814
CHILD & ADULT CARE FOOD PROGRAM
Family Educational Network of Weld County
AGREEMENT FOR CHILD CARE CENTER OR Name of Center or Sponsor
SPONSOR OF CHILD CARE CENTERS
In order to carry out the purpose of Section 17 of the National School c. Collect family size and income information on the Income
Lunch Act, as amended, and the Regulations governing the Child & Eligibility Form(IEF)for children enrolled at all the centers listed
Adult Care Food Program(CACFP)issued thereunder(7 CFR Part 226) on Schedule A to determine which children are from families
the Colorado Department of Health(hereinafter referred to as the State meeting the income eligibility guidelines for free or reduced
Agency),and the Center or Sponsor,whose name and address appear meals.Children for whom family size and income information is
above, agree as follows: not available shall be reported under the paid (not eligible for
free or reduced meals)category only. An IEF is valid for 12
THE STATE AGENCY AGREES THAT: months from the date the center or sponsor approves it.
Meals may be claimed for reimbursement beginning with
To the extent of funds available, it shall reimburse the institution for that date. It is never retroactive from the approval date.
creditable meals served to eligible children at child care centers listed Meals claimed after the expiration date can only be
on Schedule A attached hereto, during the effective period of this claimed in the paid category.
Agreement.During any fiscal year,the amount of reimbursement paid to
the center or sponsor shall be based on actual count of meals served by d. Claim reimbursement only for meals served to eligible enrolled
eligibility category. children in each income category within the limits of the license
• or registration certificate.No more than 2 meals and 1 snack per
child shall be claimed.However,if a child is in care over 8 hours,
THE CENTER OR SPONSOR AGREES THAT: then an additional meal or snack may be claimed per child. In
this case,sign-in/sign-out sheets must be kept for all children
1. It will comply with Title VI of the Civil Rights Act of 1964 (P.L.88- claimed on the CACFP.
352) and all requirements imposed by the regulations of the
Department of Agriculture(7 CFR Part 15), Department of Justice e. Submit Claims for Reimbursement in accordance with pro-
(28 CFR Parts 42 and 50),and FNS directives or regulations issued cedures established by the State Agency. Claims that are
pursuant to that Act and the regulations,to the effect that,no per- received by the State Agency after noon on the 10th of the
son in the United States shall, on the ground of race, color, sex, month shall be processed for payment the following month.Only
national origin or ancestry,age,or handicap,be excluded from par- final claims received within 60 days following the close of the
ticipation in,be denied the benefits of,or be otherwise subject to claim month shall be eligible for reimbursement.
discrimination under any program or activity for which the institu-
tion receives Federal financial assistance from the State Agency f. Store, prepare, and serve food in conformance with all applic-
and hereby gives assurance that it will immediately take any able State and local health laws and regulations.
measures necessary to effectuate this Agreement.This assurance
is given in consideration of and for the purpose of obtaining any and g, Use cash-received-in-lieu-of commodities for the purchase of
all Federal financial assistance,grants,and loans of Federal funds, food.
reimbursable expenditures,grant or donations of Federal property.
By accepting this assurance,the institution agrees to compile data. h. Maintain full and accurate records of the Pro maintain records, and submit reports as required,to permit effec- gram, and
tive enforcement of Title VI and permit authorization personnel dur- retain such records for a period of three years and four
ing normal working hours to review such records, books. and months after the end of the fiscal year to which they
accounts as needed to ascertain compliance with Title VI. If there pertain.
are any violations of this assurance,the Department of Agriculture,
Food and Nutrition Service,or the State Agency,shall have the right i. Make all accounts and records pertaining to the Program avail-
to seek judicial enforcement of this assurance.This assurance is able to the State Agency and to USDA for audit or review at a
binding on the center or sponsor,its successors,transferees,and reasonable time and place.
assignees as long as it receives assistance or retains possession of
any assistance from the State Agency. j. Provide adequate supervisory and operational personnel for
overall monitoring and management of each food service opera-
2. The governing body is responsible for the administration of the tion, and to promptly take such actions that are necessary to
centers listed on Schedule A of this Agreement,or it is an agency to correct deficiencies found at the time of any onsite visit,review,
which the centers listed on Schedule A have delegated authority or audit.
for the operation of the food service program.
k If a sponsor, monitor all centers at least 3 times each year,
3. In order to qualify for reimbursement under this Agreement,it shall including once during the first 6 weeks of CACFP operation.
conduct the Program in accordance with regulations governing the These reviews cannot be more than 6 months apart.All outside-
Child & Adult Care Food Program (7 CFR Part 226), appropriate school-hours centers must be monitored at least 6 times each
OMB circulars, State regulations, State Agency policies, and year,including once during the first month of CACFP operation.
specifically, shall conform to the following requirements: These reviews cannot be more than 3 months apart.
a. Operate a nonprofit food service using all of the income solely 4. It is a public organization or a nonprofit organization which has tax
for the operation or improvement of such service. exempt status such as under section 501(a) of the Internal
Revenue Code of 1954, or is moving toward compliance with the
b. Serve meals which meet the minimum nutritional requirements requirements of the aforementioned section in accordance with
specified in Schedule B of this Agreement. Section 226.16 of the Program regulations.
-or-
Serve the same meal at no separate charge from tuition to If a For Profit Title XX center,it certifies that it receives funds under
enrolled children who are in attendance at meal time(non- Title XX of the Social Security Act for at least 25 percent of each
pricing institution) and so designate on Application Form center's enrolled children during the month preceding application
and Nondiscrimination Policy Statement and abide by the to or renewal of the Program and shall continue to certify such infor-
terms of the Nondiscrimination Policy Statement and Pro- mation in each succeeding month. The institution shall not claim
gram Verification Rules (Regulations 226.23 h.l), reimbursement for meals served in any For Profit center for any
-or- month during which the center receives Title XX funds for less than
Have an identifiable separate charge from tuition for meals 25 percent of its enrolled children.
served to enrolled children (pricing institution) and so
designate on Application Form and Nondiscrimination 5. All child care centers listed on Schedule A have a valid license or
Policy Statement and abide by the terms of the Nondis- registration certificate for providing child care.
crimination Policy Statement and Program Verification
Rules (Regulations 226.23 h.2). 6. It provides organized child care in noeldeY f satugtions.
CACFP 300(5/90) PAGE ONE
7. It accepts final financial and administrative responsibility for total The Agreement may be terminated upon ten(10)days written notice on
CACFP operations for each child care center under its juris- the part of either party hereto,and the State Agency may terminate this
diction. Agreement immediately after receipt of evidence that the terms and
conditions of this Agreement and of the regulations governing the Pro-
8. It will annually make available to the local media serving the area gram have not been fully complied with by the center or sponsor.Any
from which the center or sponsor draws its attendance, a public termination of this Agreement by the State Agency shall be in accord
release announcing the availability of meals to all eligible enrolled with applicable laws and regulations(Federal Regulations 226.6 10c).
children without regard to race, color, sex, national origin, age, No termination or expiration of this Agreement,however,shall affect the
or handicap. obligation of the center or sponsor to maintain and retain records and to
make such records available for audit.A center or sponsor may appeal a
termination according to procedures outlined in 7 CFR Part 226.
9. It understands and agrees that any materials developed with Pro-
gram funds by the center or sponsor may be freely pro-
duced, The terms of this Agreement shall not be modified or changed in any
the Co or otherwise used by the USDA Food and Nutrition Service, way other than b the consent in writing of both parties hereto.
the Colorado Department of Health,or by other institutions under Y by
the Child& Adult Care Food Program.
. RECORDKEEPING REQUIREMENTS
THE STATE AGENCY AND CENTER OR SPONSOR MUTUALLY The center or sponsor must keep full and accurate records pertaining to
AGREE THAT: its food service as a basis for the Claim for Reimbursement and for audit
and review purposes. The records to be kept include the following:
1. Schedule A,listing centers approved for participation and meals to
be claimed for reimbursement,shall be a part of this Agreement. 1. Menus and food production records indicating quantities of foods
Centers or meals may be added to or deleted from Schedule A prepared,number of persons prepared for,and serving sizes.The
as the need arises. All such changes must be confirmed in food production record must include the number of adults
writing and sent to the State Agency. All such references to served.
Schedule A shall be deemed to include such Schedule as sup-
plemented and amended. 2. Daily record of meals served to children broken down by name by
type of meal (breakfast, lunch, supper, or snack) and by income
2. The State Agency shall notify the center or sponsor of any change category - free, reduced, or paid (Record of Meals Served form).
in the minimum meal requirements or in the applicable rates of
reimbursement as soon as possible after notification from USDA.
3. Approved Income Eligibility Forms for enrolled children categorized
as free or reduced.
3. The center or sponsor may contract with a local school food
authority or with a food service management company for the prep- 4 Documentation of income to the food service operation from funds
prep-
aration and delivery of meals or meal components.The center or
sponsor shall remain responsible for fulfillment of the terms of the to subsidize food service program,from State Agency CACFP reim-
Agreement.The center or sponsor must submit a copy of this con- bursement,from payments for adult meals and from all other sour-
tract to the State Agency. ces, including loans and donations to the food service program.
4. For the purposes of this Agreement the following terms shall 5. Invoices or receipts from food service operation purchases includ-
mean, respectively: ing bills from food service management companies,payroll records
including fringe benefits,equipment costs,maintenance and repair
fees,office costs, utilities costs and other administrative costs.
DEFINITIONS
"Children"means(a)persons up to their 13th birthday and under, This documentation shall ensure that all reimbursement funds are
(b)children of migrant workers 15 years of age and under,and(c) used:(1)solely for the conduct of the food service,or(2)to improve
mentally or physically handicapped persons, as defined by the such food service operations principally for the benefit of the
State Agency,enrolled in an institution or child care facility serving enrolled children.DOCUMENTATION OF ALL COSTS PERTAIN-
a majority of persons 18 years of age and under. ING TO THE OPERATION OF THE CACFP MUST BE SPECIFIC-
ALLY ITEMIZED. DOCUMENTATION MUST CLEARLY SHOW
THAT THE FOOD SERVICE IS NONPROFIT BASED ON ALL
"Enrolled child"means a child whose parent or guardian has sub- CACFP INCOME AND EXPENSES.
mitted to the center or sponsor signed document which indicates
that the child is enrolled for child care. 6. License, registration, or certification documentation
"Milk" means pasteurized fluid types of unflavored or flavored 7. Documentation of visits to child care centers to monitor com-
whole milk,lowfat milk skim milk,or cultured buttermilk which meet Documentation
.This requirement pertains carenly enters sponsors who o monitor
com-
State and local standards for such milk except that,in the meal pat- plianc n more than one child care center in accordance with Federal
ister
tern for infants(0 to l year of age),"milk"means unflavored types of Regulationtha one (d).
whole fluid milk or an equivalent quantity of reconstituted
evaporated milk which meets such standards.All milk should con-
tain vitamins A and D at levels specified by the Food and Drug 8. Documentation of enrollment
Administration and be consistent with State and local standards for
such milk. 9. Documentation of attendance (rollbooks or sign in/sign out
sheets)
"Verification" means a review of the information reported by the
center or sponsor to the State Agency regarding the eligiblity of 10. Documentation of Civil Rights racial/ethnic data
enrolled children for free or reduced meals.
11. Documentation of staff training pertaining to CACFP
This Agreement shall be effective with respect to meals served
during the period commencing the 1st day of October 1990 and 12. Copy of press release sent annually to the media
ending September 30, 1992 unless terminated earlier as herein
provided.The State Agency may renew this Agreement, by notice in 13. Special Diet Statement or Special Diet Statement for Handicapped
writing given to the center or sponsor,for such period as funds are avail- Child documentingDiet
Statement
Special
ial the CACFP meal patterns.
able for carrying out the Program.The State Agency Agreement to reim-
burse the center or sponsor is conditioned upon the continued
availability of funds appropriated for Child 8,Adult Care Food Program in 14. Food service management company contract or other food
a sufficient amounts and no legal liability on the part of the Government service contracts.
for the payment of any money shall arise unless and until such appropri-
ation shall have been provided. 15. All Department of Social Services contract(s) - For Profit Title XX
centers only.
16. Record of payment and billing forms from Department of Social
Services - For Profit Title XX centers only
17. Record of deposit of CACFP reimbursement
PAGE TWO
SCHEDULE
Fill in the name and address of centers participating in the Child 8 Adult Care Food Program.
(Attach additional sheets if necessary.)
HOURS AND TYPE OF MEALS SERVED
TYPE OF No more than 2 meals and 1 snack per child
shall be claimed.
CENTER
DEPARTMENT OF However, it a child is in care over 8 hours, then an
NAME AND ADDRESS ^ Cnila care center SOCIAL SERVICES additional meal or snack may be claimed per child.
H - MedQ Start School OF CENTER a - OutsideHoare BREAK- AM PM
P • For Profit Title LICENSE
Title%X NUMBER FAST SNACK LUNCH SNACK SUPPER
Greeley, Migrant Head H 58236 7:30 11-11:30 3:00
Start
520 13 Avenue
Greeley, CO 80631
Frederick, Migrant Head H 66816 7:30 11-11:30 3:00
Start
341 Maple, -
Frederick, CO 80530
Brighton, Migrant Head H pending see 7:30 11-11:3) 3:00
Start attached
675 Egbert
Brighton, CO 80601
Fort Collins, Migrant H pending see 7:30 11-11:3) 3:00
Head Start attached
',!Werner Elementary School
5400 Mail Creek Rd.
Fort Collins, CO 80525
Fort Morgan, Migrant H pending 8:00 11 :30 2:30
Head Start
Baker Elementary School
300 Lake St.
Fort Morgan, CO 80701
5 1.0�sf1"y
PAGE THREE
SCHEDULE B
Requirements for Meals — Child & Adult Care Food Program
Each institution participating in the Program shall serve one or more of
the following types of meals,as provided in its approved application:(1) (2) Lunch of lean eat, cup of milk;1 or 1 ounce
un eof portion a r
Breakfast, (2) Lunch, (3) Supper, (4) Snacks served between such 1ervg,or /4 cup of poultry,or fish,beans or peas; or 2tocheese,B-
other meals. 1 egg,or 1/4 cup of cooked dry beans or peas; or 2 table-
spoons of peanut butter; 1/4 cup of vegetables or fruits or
t. Except as otherwise provided in this section,and in an a both consisting of two or more kinds; 1/2 slice of bread or
this part, each meal shall contain, as a minimum, the food com- grain rice, macaroni,bread alternate, or /4 cup of cooked enriched
nood es, Or otherr pastaproducts.
hOle-
ponents as follows:
a. A breakfast shall contain: (3) Snack—select two of the following four components-1/2
cup of milk; 1/2 ounce of meat or(1) A serving of fluid milk as a beverage,or on cereal,or used in includes 2 ounces or 1/4 cup of yogurt)meat; ternate of juice,or
part for each purpose. equivalent quantity of fruit,or vegetables; 1/2 slice of bread
(2) A serving of vegetable(s)or fruit or full-strength vegetable or or(weight), is less,of cer cup ealoloml/4 cup 3 ounces
of cooked
fruit juice, or an equivalent quantity of any combination of (wet p
enriched or whole-grain rice, macaroni, noodles or other
these foods. pasta products.
(3) A serving of whole-grain-or enriched bread;or an equivalent b- Age 3 up [0 6:
serving of cornbread,biscuits,rolls,muffins,etc.,made with (1) Breakfast-3/4 cup of milk, 1/2 cup of juice or fruit or
whole-grain or enriched meal or flour;or a serving of whole-
grain or enriched or fortified cereal;or a serving of cooked vegetables;(volume)or 1/2/2 ounce(weight),whichever is less slice of bread or bread alternate,or ere cup
whole-grain or enriched pasta or noodle products such ash bread and cereal.1. cereal or
macaroni,or cereal grains such as rice,bulgur,or corn grits; an equivalent quantity of both
th se equivalent quantity of any combination of any of
these foods. (2) Lunch or supper-3/4 cup of milk, 1 1/2 ounces(edible por-
tion as served)of lean meat,poultry,or fish,or 1 1/2 ounces
of cheese,or 1 egg,or 3/8 cup of cooked dry beans or peas,
b. Both lunch and supper shall contain:
or 3 tablespoons of peanut butter; 1/2 cup of vegetables or
(1) A serving of fluid milk as a beverage. fruits or both consisting of two or more kinds, 1/2 slice of
bread or bread alternate,or 1/4 cup of cooked enriched or
(2) A serving of lean meat,poultry or fish;or cheese;or an egg;or whole-grain rice, macaroni, noodles or other pasta
cooked dry beans or peas; or nuts or nut butters; or an products.
equivalent quantity of any combination of these foods.These
foods must be served in a main dish,or in a main dish and one (3) Snack—select two of the following components-1/2 cup of
oor ther menu item,to meet this requirement.Cooked dry beans milk; 1/2 ounce of meat or meat alternate(which includes 2 art of the ounces vegetable/fruit eas component be used as the meat
not asaslternate or as both food components equivalentr 1/4 cup quant quantity of fruit or vegetables;s 1/2 up/2 sl of ice of bread
in the same meal. or bread alternate;or l/3 cu
whichever is less,of cereal,o(volume)r1/4 cup of cooked enriched or 1/2 ounce(weight),
(3) A serving of two or more vegetables or fruits,or a combination whole-grain rice, macaroni, noodles,or other pasta products.
of both.Full-strength vegetable or fruit juice may be counted
to meet not more than one-half of this requirement. c. Age 6 through 12
(4) A serving of whole-grain or enriched bread; or an equivalent (1) Breakfast-1 cup of milk; 1/2 cup of juice or fruit or
serving of cornbread, biscuits, rolls, muffins, etc., made of vegetables; 1 slice of bread or bread alternate, or 3/4
ere cup
whole-grain or enriched meal or flour;or a serving of cooked (volume) t 1 ounce(weight),whichever is less,of cereal or
whole-grain or enriched pasta or noodle products such as equivalent quantity of both bread and cereal.
macaroni,or cereal grains such as rice,bulgur,or corn grits;or
an equivalent quantity of any combination of these foods. (2) Lunch or supper-1 cup of milk;2 ounces(edible portion as
served)of lean meat,poultry,or fish,or 2 ounces of cheese
c. Snack shall be served between other meal types and contain two or t egg,or 1/2 cup of cooked dry beans or peas,or 4 table-
of the following four components: spoons of peanut butter; 3/4 cup of vegetables or fruits or
both consisting of two or more kinds; 1 slice of bread or
(11 A serving of fluid milk as a beverage,or on cereal,or used in bread alternate, or 1/2 cup of cooked enriched or whole-
part for each purpose. grain rice, macaroni, noodles or other pasta products.
(2) A serving of meat or meat alternate. (3) Snack—select two of the following four components-1 cup
of milk; 1 ounce of meat or meat alternate(which includes 4
(3) A serving of vegetable(s)or fru it(s)or full-strength vegetable ounces or 1/2 cup of yogurt);3/4 juice or equivalent quantity
or fruit juice,or an equivalent quantity of any combination of of fruit or vegetables; 1 slice of bread or bread alternate,or
3/4 cup (volume)or i ounce(weight),whichever is less,of
these foods.Juice may not be served when milk is served as
the only other component. cereal or 1/2 cup of cooked, enriched or whole-grain rice,
macaroni, noodles or other pasta products.
(4) A serving of whole-grain or enriched bread;or an equivalent
d. Age 12 and over:Adult-sized portions based on the greater food
serving of cornbread,biscuits,rolls, muffins,etc.made with
whole-grain or enriched meal or flour;or a serving of whole- needs of older boys and girls.
grain or enriched or fortified cereal;or a serving of cooked
whole-grain or enriched pasta or noodle products such as e. Infant meal patterns:
macaroni,or cereal grains such as rice,bulgur,or corn grits:
or an equivalent quantity of any combination of these (i) 0 through 3 months;
foods. (a) Breakfast-4-6 fluid ounces of iron-fortified infant
formula.
2. Except as otherwise provided in this section the minimum amounts
of component foods to serve at meals as set forth in subparagraphs (b) Lunch or supper-4-6 fluid ounces of iron-fortified
(b) (1), (2), and (3) of this section are as follows: infant formula.
a. Age 1 up to 3;
(1) Breakfast-1/2 cup of milk, 1/4 cup of juice or fruit or (c) Snack-4-6 fluid ounces of iron-fortified infant formula.
vegetables,1/2 slice of bread or bread alternate,or 1/4 cup (2) 4 through 7 months;
(volume)or 1/3 ounce(weight),whichever is less,of cereal or
(a) Breakfast-4-8 fluid ounces of iron-fortified infant for-
an equivalent quantity of both bread and cereal.
mule, 0-3 tablespoons of iron-fortified dry infant cereal
PAGE FOUR (optionaoi nit:l).
v'i_lio '
'
(b) Lunch or supper-4-8 fluid ounces of iron-fortified infant
a. Breakfast:
formula; 0-3 tablespoons of iron-fortified dry infant
cereal(optional);0-3 tablespoons of fruit or vegetable of (1) Include as often as practical an egg,or a 1-ounce serving
appropriate consistency or a combination of both (edible portion as served)of meat,poultry or fish;or 1 ounce
optional). of cheese; or 2 tablespoons of peanut butter or an
( equivalent quantity of any combination of these foods.
(c) Snack-4-6 fluid ounces of iron-fortified infant formula. (2) Additional foods may be served as desired.
(3) 8 months up to the first birthday; b. Lunch or supper: Additional foods may be served as desired.
(a) Breakfast-6-8 fluid ounces of iron-fortified infant fomula
or 6-8 fluid ounces of whole milk;2-4 tablespoons of iron- c. Snack: Include as often as practical a serving of meat or alter-
fortified dry infant cereal; 1.4 tablespoons of fruit or nate such as peanut butter or cheese or other foods needed to
vegetable of appropriate consistency or a combination of satisfy appetites.
both.
5. If emergency conditions prevent an institution normally having a
(b) Lunch or supper-6-8 fluid ounces of iron-fortified infant supply of milk from temporarily obtaining delivery thereof,the State
formula,or 6-8 fluid ounces whole milk;2-4 tablespoons agency,may approve the service of breakfasts,lunches,or suppers
of iron-fortified dry infant cereal and/or 1-4 tablespoons without milk during the emergency period.
of meat,fish, poultry, egg yolk or cooked dry beans or
peas,or 1/2-2 ounces(weight)of cheese or 1-4 ounces 6. Substitutions may be made in food listed in paragraphs(b),(1),(2),
(weight or volume)of cottage cheese or cheese food or and(3)of this section if individual participating children are unable,
cheese spread of appropriate consistency; and 1.4 because of medical or other special dietary needs, to consume
tablespoons of fruit or vegetable of appropriate consis- such foods.Such substitutions shall be made only when supported
tency or a combination of both. by a statement from a recognized medical authority which includes
recommended alternate foods.
(c) Snack-2-4 fluid ounces of iron-fortified infant formula,
whole fluid milk or full-strength fruit juice,0-1/2 slice of
crusty enriched or wholegrain bread (optional), or 0-2 STATE AGENCY AND CENTER OR SPONSOR FURTHER
cracker-type products(optional)made from whole grain AGREE THAT:
or enriched meal or flour and which are suitable for an
infant for use as a finger food. The center or sponsor shall accept full responsibility for providing
proper accountability,storage,and use of USDA commodity foods and
Breast milk,provided by the infant's mother,may be served in place of in so doing,shall promptly provide awritten response to claims that mis-
inf ant formula from birth through 11 months of age. However, meals handlings, diversions, and/or losses resulting from improper use or
containing only breast milk do not qualify for reimbursement. Meals storage have occurred.
containing breast milk served to infants 4 months of age or older may be
claimed for reimbursement when the other required meal component or components are supplied by the child care facility. The center or sponsor shall use USDA commodity foods received under
this Agreement solely for the benefit of those persons served or assist-
ed by the center or sponsor and shall not otherwise dispose of USDA
3. For the purpose of this section, a cup means a standard mea- commodity foods without prior written approval of the State Agency.
suring cup.
4. To improve the nutrition of participating children additional foods
may be served with each meal as follows:
SIGNATURE ON BEHALF OF CENTER OR SPONSOR
I certify that the information on this form is true and correct to the best of my knowledge.I understand that this information is being given in con-
nection with the receipt of Federal funds,and that deliberate misrepresentation may subject me to prosecution under applicable State and
Federal criminal statutes.
Si nature e
Date
Print Name nle
Please complete, sign,and return all 3 copies to the Colorado Department of Health Child 8 Adult Care Food Program.
SIGNATURES ON CHIILDHALF OF& ADULTCCARE RADO FOOD PROGRAM DEPARTMENT OF HEALTH
For the Executive Director,COIO(ad0 Department of Health
Date
Administrator,CACFP
Title Date
TO BE FILLED OUT BY COLORADO DEPARTMENT OF HEALTH, Center or Sponsor will receive for its child care centers, Head
CHILD & ADULT CARE FOOD PROGRAM: St rt Censers,outside school-hours centers, or For Profit Title
D Regular Donated Commodities
OR
❑ Cash-in-lieu of Commodities(with bonus commodities)
cal 0 tn'1/41
PAGE FIVE
COLORADO DEPARTMENT OF HEALTH Agreement Number: d4 6000814
CHILD & ADULT CARE FOOD PROGRAM
Family Educational Network of Weld County
AGREEMENT FOR CHILD CARE CENTER OR Name of Center or Sponsor
SPONSOR OF CHILD CARE CENTERS
In order to carry out the purpose of Section 17 of the National School c. Collect family size and income information on the Income
Lunch Act, as amended, and the Regulations governing the Child & Eligibility Form(IEF)for children enrolled at all the centers listed
Adult Care Food Program(CACFP)issued thereunder(7 CFR Part 226) on Schedule A to determine which children are from families
the Colorado Department of Health(hereinafter referred to as the State meeting the income eligibility guidelines for free or reduced
Agency),and the Center or Sponsor,whose name and address appear meals.Children for whom family size and income information is
above, agree as follows: not available shall be reported under the paid(not eligible for
free or reduced meals) category only. An IEF is valid for 12
THE STATE AGENCY AGREES THAT: months from the date the center or sponsor approves it.
Meals may be claimed for reimbursement beginning with
To the extent of funds available, it shall reimburse the institution for that date. It is never retroactive from the approval date.
creditable meals served to eligible children at child care centers listed Meals claimed after the expiration date can only be
on Schedule A attached hereto, during the effective period of this claimed in the paid category.
Agreement.During any fiscal year,the amount of reimbursement paid to
the center or sponsor shall be based on actual count of meals served by d. Claim reimbursement only for meals served to eligible enrolled
eligibility category. children in each income category within the limits of the license
or registration certificate.No more than 2 meals and 1 snack per
child shall be claimed.However,if a child is in care over 8 hours,
THE CENTER OR SPONSOR AGREES THAT: then an additional meal or snack may be claimed per child. In
this case,sign-in/sign-out sheets must be kept for all children
1. It will comply with Title VI of the Civil Rights Act of 1964(P.L. 88- claimed on the CACFP.
352) and all requirements imposed by the regulations of the
Department of Agriculture(7 CFR Part 15), Department of Justice e. Submit Claims for Reimbursement in accordance with pro-
(28 CFR Parts 42 and 50),and FNS directives or regulations issued cedures established by the State Agency. Claims that are
pursuant to that Act and the regulations,to the effect that,no per- received by the State Agency after noon on the 10th of the
son in the United States shall, on the ground of race, color, sex, month shall be processed for payment the following month.Only
national origin or ancestry,age,or handicap,be excluded from par- final claims received within 60 days following the close of the
ticipation in, be denied the benefits of,or be otherwise subject to claim month shall be eligible for reimbursement.
discrimination under any program or activity for which the institu-
tion receives Federal financial assistance from the State Agency f. Store, prepare,and serve food in conformance with all applic-
and hereby gives assurance that it will immediately take any able State and local health laws and regulations.
measures necessary to effectuate this Agreement.This assurance
is given in consideration of and for the purpose of obtaining any and g, Use cash-received-in-lieu-of commodities for the purchase of
all Federal financial assistance,grants,and loans of Federal funds, food.
reimbursable expenditures,grant or donations of Federal property.
By accepting this assurance,the institution agrees to compile data,
maintain records,and submit reports as required,to permit effec- h. Maintain full and accurate records of the Program, and
tive enforcement of Title VI and permit authorization personnel dur- retain such records for a period of three years and four
ing normal working hours to review such records, books, and months after the end of the fiscal year to which they
accounts as needed to ascertain compliance with Title VI. If there pertain.
are any violations of this assurance,the Department of Agriculture,
Food and Nutrition Service,or the State Agency,shall have the right i. Make all accounts and records pertaining to the Program avail-
to seek judicial enforcement of this assurance.This assurance is able to the State Agency and to USDA for audit or review at a
binding on the center or sponsor,its successors,transferees,and reasonable time and place.
assignees as long as it receives assistance or retains possession of
any assistance from the State Agency. j. Provide adequate supervisory and operational personnel for
overall monitoring and management of each food service opera-
2. The governing body is responsible for the administration of the tion, and to promptly take such actions that are necessary to
centers listed on Schedule A of this Agreement,or it is an agency to correct deficiencies found at the time of any onsite visit,review,
which the centers listed on Schedule A have delegated authority or audit.
for the operation of the food service program.
k. If a sponsor, monitor all centers at least 3 times each year,
3. In order to qualify for reimbursement under this Agreement,it shall including once during the first 6 weeks of CACFP operation.
conduct the Program in accordance with regulations governing the These reviews cannot be more than 6 months apart.All outside-
Child & Adult Care Food Program (7 CFR Part 226), appropriate school-hours centers must be monitored at least 6 times each
OMB circulars, State regulations, State Agency policies, and year,including once during the first month of CACFP operation.
specifically, shall conform to the following requirements: These reviews cannot be more than 3 months apart.
a. Operate a nonprofit food service using all of the income solely 4. It is a public organization or a nonprofit organization which has tax
for the operation or improvement of such service. exempt status such as under section 501(a) of the Internal
Revenue Code of 1954,or is moving toward compliance with the
b. Serve meals which meet the minimum nutritional requirements requirements of the aforementioned section in accordance with
specified in Schedule B of this Agreement. Section 226.16 of the Program regulations.
-or-
Serve the same meal at no separate charge from tuition to If a For Profit Title XX center,it certifies that it receives funds under
enrolled children who are in attendance at meal time(non- Title XX of the Social Security Act for at least 25 percent of each
pricing institution)and so designate on Application Form centers enrolled children during the month preceding application
and Nondiscrimination Policy Statement and abide by the to or renewal of the Program and shall continue to certify such infor-
terms of the Nondiscrimination Policy Statement and Pro- mation in each succeeding month.The institution shall not claim
gram Verification Rules(Regulations 226.23 h.l), reimbursement for meals served in any For Profit center for any
-or- month during which the center receives Title XX funds for less than
Have an identifiable separate charge from tuition for meals 25 percent of its enrolled children.
served to enrolled children (pricing institution) and so
designate on Application Form and Nondiscrimination 5. All child care centers listed on Schedule A have a valid license or
Policy Statement and abide by the terms of the Nondis- registration certificate for providing child care.
crimination Policy Statement and Program Verification
Rules(Regulations 226.23 h.2). 6. It provides organized child care in nonresidential situations.
CACFP 300(5/90) PAGE ONE O1 na1:'1.n,1
7. It accepts final financial and administrative responsibility for total The Agreement may be terminated upon ten(10)days written notice on
CACFP operations for each child care center under its juris- the part of either party hereto,and the State Agency may terminate this
diction. Agreement immediately after receipt of evidence that the terms and
conditions of this Agreement and of the regulations governing the Pro-
8. It will annually make available to the local media serving the area gram have not been fully complied with by the center or sponsor.Any
from which the center or sponsor draws its attendance, a public termination of this Agreement by the State Agency shall be in accord
release announcing the availability of meals to all eligible enrolled with applicable laws and regulations(Federal Regulations 226.6 10c).
children without regard to race, color, sex, national origin, age, No termination or expiration of this Agreement,however,shall affect the
or handicap. obligation of the center or sponsor to maintain and retain records and to
make such records available for audit.A center or sponsor may appeal a
termination according to procedures outlined in 7 CFR Part 226.
9. It understands and agrees that any materials developed with Pro-
gramfundsbythecenterorsponsormaybefreelyreproduced,pro- The terms of this Agreement shall not be modified or changed in any
duced,or otherwise used by the USDA Food and Nutrition Service, other than b the consent l writing m both parties hereto.
the Colorado Department of Health,or by other institutions under y y
the Child 8 Adult Care Food Program.
RECORDKEEPING REQUIREMENTS
•
THE STATE AGENCY AND CENTER OR SPONSOR MUTUALLY The center or sponsor must keep full and accurate records pertaining to
AGREE THAT: its food service as a basis for the Claim for Reimbursement and for audit
and review purposes. The records to be kept include the following:
1. Schedule A,listing centers approved for participation and meals to
be claimed for reimbursement,shall be a part of this Agreement. 1. Menus and food production records indicating quantities of foods
Centers or meals may be added to or deleted from Schedule A prepared,number of persons prepared for,and serving sizes.The
as the need arises. All such changes must be confirmed in food production record must include the number of adults
writing and sent to the State Agency. All such references to served.
Schedule A shall be deemed to include such Schedule as sup-
plemented and amended. 2. Daily record of meals served to children broken down by name by
type of meal (breakfast, lunch, supper, or snack) and by income
2. The State Agency shall notify the center or sponsor of any change category -free, reduced,or paid (Record of Meals Served form).
in the minimum meal requirements or in the applicable rates of
reimbursement as soon as possible after notification from USDA. 3. Approved Income Eligibility Forms for enrolled children categorized
as free or reduced.
3. The center or sponsor may contract with a local school food
authority or with a food service management company for the prep-
aration and delivery of meals or meal components.The center or 4. Documentation of income to the food service operation from funds
sponsor shall remain responsible for fulfillment of the terms of the to subsidize food service program,from State Agency CACFP reim-
pon bursement,from payments for adult meals and from all other sour-
Agreement.The center or sponsor must submit a copy of this con- ces, including loans and donations to the food service program.
tract to the State Agency.
4. For the purposes of this Agreement the following terms shall 5. Invoiinclud-
ing bills s from food service es or receipts from fmanagement companies,payroll ood service operation sr records
mean, respectively: including fringe benefits,equipment costs,maintenance and repair
fees,office costs, utilities costs and other administrative costs.
DEFINITIONS •
"Children" means(a)persons up to their 13th birthday and under, This documentation shall ensure that all reimbursement funds are
used:(1)solely for the conduct of the food service,or(2)to improve
(b)children of migrant workers 16 years of age and under,and he such food service operations principally for the benefit of the
mentally n physically handicapped persons, a defined er the enrolled children.DOCUMENTATION OF ALL COSTS PERTAIN-
StateArity of enrolled in an institution age a child care facility serving ING TO THE OPERATION OF THE CACFP MUST BE SPECIFIC-
ALLY ITEMIZED. DOCUMENTATION MUST CLEARLY SHOW
THAT THE FOOD SERVICE IS NONPROFIT BASED ON ALL
"Enrolled child" means a child whose parent or guardian has sub- CACFP INCOME AND EXPENSES.
mitted to the center or sponsor a signed document which indicates
that the child is enrolled for child care. 6. License, registration, or certification documentation
"Milk" means pasteurized fluid types of unflavored or flavored 7. Documentation of visits to child care centers to monitor com-
wateanll local
standards for
milk, milk except
buttermilk which meet pliance.This requirement pertains only to sponsors who administer
State and local standards for such milk except that,in the meal pat- more than one child care center in accordance with Federal
tern for infants it to r an oequivalmilk"means unff recd types of Regulation 226.16(d).
whole fluid milk or an equivalent quantity of reconstituted g
evaporated milk which meets such standards.All milk should con-
tain vitamins A and D at levels specified by the Food and Drug 8. Documentation of enrollment
Administration and be consistent with State and local standards for
such milk. 9. Documentation of attendance (rollbooks or sign in/sign out
sheets)
"Verification" means a review of the information reported by the
center or sponsor to the State Agency regarding the eligiblity of 10. Documentation of Civil Rights racial/ethnic data
enrolled children for free or reduced meals.
11. Documentation of staff training pertaining to CACFP
This Agreement shall be effective with respect to meals served
during the period commencing the 1st day of October 1990 and 12. Copy of press release sent annually to the media
ending September 30, 1992 unless terminated earlier as herein
provided.The State Agency may renew this Agreement, by notice in 13. Special Diet Statement or Special Diet Statement for Handicapped
writing given to the center or sponsor,for such period as funds are avail- Child documenting variances from the CACFP meal patterns.
able for carrying out the Program.The State Agency Agreement to reim-
burse the center or sponsor is conditioned upon the continued
availability of funds appropriated for Child B Adult Care Food Program in 14. Food service management company contract or other food
a sufficient amount,and no legal liability on the part of the Government service contracts.
for the payment of any money shall arise unless and until such appropri- 15. All Department of Social Services contract(s) - For Profit Title XX
ation shall have been provided.
centers only.
16. Record of payment and billing forms from Department of Social
Services - For Profit Title XX centers only
17. Record of deposit of CACFP reimbursement
PAGE TWO + q�
0 YP-v_Y r j itf'')
SCHEDULE A
Fill in the name and address of centers participating in the Child&Adult Care Food Program.
(Attach additional sheets it necessary.)
HOURS AND TYPE OF MEALS SERVED
TYPE OF No more than 2 meals and 1 snack per child
CENTER shall be claimed.
DEPARTMENT OF However, it a child is in care over 8 hours, then an
NAME AND ADDRESS c child care CenterSOCIAL SERVICES additional meal or snack may be claimed per child.
H Head Start
OFCENTER 0 Outside School Hours LICENSE BREAK- AM PM
P- For Profit Title%% NUMBER FAST SNACK LUNCH SNACK SUPPER
Greeley, Migrant Head H 58236 7:30 11-11:30 3:00
Start
520 13 Avenue
Greeley, CO 80631
Frederick, Migrant Head H 66816 7:30 11-11:30 3:00
Start
341 Maple,
Frederick, CO 80530
Brighton, Migrant Head H pending see 7:30 11-11:30 3:00
Start attached
675 Egbert
Brighton, CO 80601
Fort Collins, Migrant H pending see 7:30 11-11:3) 3:00
Head Start attached
A4erner Elementary School
5400 Mail Creek Rd.
Fort Collins, CO 80525
Fort Morgan, Migrant H pending 8:00 11 :30 2:30
Head Start
Baker Elementary School
300 Lake St.
Fort Morgan, CO 80701
(A Armen
PAGE THREE _
SCHEDULE B
Requirements for Meals — Child & Adult Care Food Program
Each institution participating in the Program shall serve one or more of (2) Lunch or supper-1/2 cup of milk;1 ounce(edible portion as
the following types of meals,as provided in its approved application:(1) served)of lean meat,poultry,or fish,or 1 ounce of cheese,or
Breakfast, (2) Lunch, (3) Supper, (4) Snacks served between such 1 egg,or 1/4 cup of cooked dry beans or peas;or 2 table-
other meals. spoons of peanut butter; 1/4 cup of vegetables or fruits or
both consisting of two or more kinds; 1/2 slice of bread or
1. Except as otherwise provided in this section,and in any appendix to bread alternate, or 1/4 cup of cooked enriched or whole-
this part, each meal shall contain, as a minimum, the food com- grain rice, macaroni, noodles, or other pasta products.
ponents as follows:
a. A breakfast shall contain: (3) Snack—select two of the following four components-1/2
cup of milk; 1/2 ounce of meat or meat alternate (which
(1) A serving of fluid milk as a beverage,or on cereal,or used in includes 2 ounces or 1/4 cup of yogurt); 1/2 cup of juice,or
part for each purpose. equivalent quantity of fruit,or vegetables; 1/2 slice of bread
or bread alternate. or 1/4 cup (volume) or 1/3 ounces
(weight),whichever is less,of cereal,or 1/4 cup of cooked
(2) A serving of vegetable(s)or fruit or full-strength vegetable or
fruit juice, or an equivalent quantity of any combination of enriched or whole-grain rice, macaroni, noodles or other
pasta products.
these foods.
(3) A serving of whole-grain or enriched bread;or an equivalent b. Age 3 up to 6:
serving of cornbread,biscuits,rolls,muffins,etc.,made with (1) Breakfast-3/4 cup of milk, 1/2 cup of juice or fruit or
whole-grain or enriched meal or flour;or a serving of whole- vegetables;1/2 slice of bread or bread alternate,or 1/3 cup
grain or enriched or fortified cereal;or a serving of cooked (volume)or 1/2 ounce(weight),whichever is less of cereal or
whole-grain or enriched pasta or noodle products such as an equivalent quantity of both bread and cereal.
macaroni,or cereal grains such as rice,bulgur,or corn grits;
or an equivalent quantity of any combination of any of 2 Lunch or supper-3/4
these foods. ( ) cup t, milk,1 or
ounces(edible por-
tion as served)of lean meat,poultry,or fish,or 1 1/2 ounces
of cheese,or 1 egg,or 3/8 cup of cooked dry beans or peas,
b. Both lunch and supper shall contain: or 3 tablespoons of peanut butter; 1/2 cup of vegetables or
(1) A serving of fluid milk as a beverage. fruits or both consisting of two or more kinds. 1/2 slice of
bread or bread alternate,or 1/4 cup of cooked enriched or
roduucts.cts.
(2) A serving of lean meat,poultry or fish;or cheese;or an egg;or products.
o n rice, macaroni, noodles or other pasta
cooked dry beans or peas; or nuts or nut butters; or an pr
equivalent quantity of any combination of these foods.These
foods must be served in a main dish,or in a main dish and one (3) Snack—select two of the following components-1/2 cup of
other menu item,to meet this requirement.Cooked dry beans milk;1/2 ounce of meat or meat altemate(which includes 2
or dry peas may be used as the meat alternate or as part of the ounces or 1/4 cup of yogurt); 1/2 cup of juice or an
vegetable/fruit component,but not as both food components equivalent quantity of fruit or vegetables; 1/2 slice of bread
in the same meal. or bread alternate;or 1/3 cup(volume)or 1/2 ounce(weight),
whichever is less,of cereal,or 1/4 cup of cooked enriched or
(3) Aserving of two or more vegetables ar fruits,oracombination whole-grain rice, macaroni, noodles,or other pasta products.
of both.Full-strength vegetable or fruit juice may be counted
to meet not more than one-half of this requirement. c. Age 6 through 12
(4) A serving of whole-grain or enriched bread; or an equivalent (1) Breakfasts; cup of milk; 1/2 cup Itf juice or fruit p
9 vegetables; 1 slice of bread or bread alternate,or 3/4 cup
serving of cornbread, biscuits, rolls, muffins, etc., made of (volume)or 1 ounce(weight),whichever is less,of cereal or
whole-grain or enriched meal or flour;or a serving of cooked equivalent quantity of both bread and cereal.
whole-grain or enriched pasta or noodle products such as
macaroni,or cereal grains such as rice,bulgur,or com grits:or (2) Lunch or supper-1 cup of milk;2 ounces(edible portion as
an equivalent quantity of any combination of these foods. served)of lean meat,poultry,or fish,or 2 ounces of cheese
or 1 egg,or 1/2 cup oft cooked dry beans et peas,or 4 table-
c. Snack shall be served between other meal types and contain two spoons of peanut butter; 3/4 cup of vegetables or fruits or
of the following four components: both consisting of two or more kinds; 1 slice of bread or
(1) A serving of fluid milk as a beverage,or on cereal,or used in bread alternate, or 1/2 cup of cooked enriched or whole-
part for each purpose. grain rice, macaroni, noodles or other pasta products.
(2) A serving of meat or meat alternate. (3) Snack—select two of the following four components-1 cup
of milk; 1 ounce of meat or meat alternate(which includes 4
ounces or 1/2 cup of yogurt);3/4 juice or equivalent quantity
(3) Aserving of vegetable(s)orfruit(s)or full-strength vegetable
of fruit or vegetables; 1 slice of bread or bread alternate,or
or fruit juice,or an equivalent quantity of any combination of
3/4 cup(volume) or 1 ounce(weight),whichever is less,of
these foods.Juice may not be served when milk is served as cereal or 1/2 cup of cooked, enriched or whole-grain rice,
the only other component. macaroni, noodles or other pasta products.
(4) A serving of whole-grain or enriched bread;or an equivalent d. Age 12 and over:Adult-sized portions based on the greater food
serving of cornbread,biscuits,rolls,muffins,etc.made with needs of older boys and girls.
whole-grain or enriched meal or flour;or a serving of whole-
grain or enriched or fortified cereal; or a serving of cooked
whole-grain or enriched pasta or noodle products such as e. Infant meal patterns:
macaroni,or cereal grains such as rice,bulgur,or corn grits; (1) 0 through 3 months;
or an equivalent quantity of any combination of these
foods. (a) Breakfast-4-6 fluid ounces of iron-fortified infant
formula.
2. Except as otherwise provided in this section the minimum amounts
of component foods to serve at meals as set forth in subparagraphs (b) Lunch or supper-4-6 fluid ounces of iron-fortified
(b) (1), (2), and (3) of this section are as follows: infant formula.
a. Age 1 up to 3; (c) Snack-4-6 fluid ounces of iron-fortified infant formula.
(1) Breakfast-1/2 cup of milk, 1/4 cup of juice or fruit or
vegetables,1/2 slice of bread or bread alternate,or 1/4 cup (2) 4 through 7 months;
(volume)or 1/3 ounce(weig ht),whichever is less,of cereal or (a) Breakfast-4-8 fluid ounces of iron-fortified infant lor-
an equivalent quantity of both bread and cereal. mula, 0-3 tablespoons of iron-fortified dry infant cereal
(optional).
PAGE FOUR Pj arrris',
pper-4-8 fluid/b)formula; 0-3 tablespoons ounces
-f iron-fortified infant
core
appropriate ) °-3 tablespoons iron-fortified gdryet infant a. Br
eakfast:
combination of both
(c) Snack-4-6 fluid ounces (1) Inclutl
ces of iron-1 (Include as often as practical an
(3) 8 month iron-fortified infant forPortion as
(a) Breakfast-6-8 s up to the first birthday; formula.
equivalent cheese; ors tablespoons t
akfast—g-8 fluid quantity of any
combir
fortified ry ounces
whole of it z 4 tabled infant iomula b. foods may be served a;
ces of
fortifiable cereal; 1-4 milk; es Lunch
both. of consistencyopa tablespoons ofs(�uit f pr h or supper:Additional food combination of °� Snack: s may
(bl Lunch or k Include as a`
formula supper-6-8 fluid satisfy a h as peanut butter practicale o
of iron- °r 6-8 fluid ounces whole mi of lk; -fortified infant
appetites.
or chess
(of meat, ou�es infant yolk or cooked dry ry a beans
or
5, supply of milk jromditions prevent
of emergency an peas,or 7/2-2 99 Yolk gent
(weight or volume)of cottage
of cheese tlry beans orns
geout•may approve temporarily obtaining shim
tablese spread o/ oettage cheese or cheese
1-4 ounces wife milk during
service of breakfast
t(wei of r volume)
fruit f tta a cheese
eseconsistency;o these food or 6. Substitutionsb the emergency period.p
P'"„Z,.. ad of combination appropriate both. pfaPpro and
1-q ( made cva_nr i$.✓ :� (ci Snack— appropriate andmay
2'4 fluff s- because his section if 'nual partd fisted p crusty whole-2-4 fluid
ounces of iron-fortified fruit info formula, such e l lernat subl or stitutions she a'dleaairy fluid milk or enriched products
is(option /made co /olgrain recommendeda stalter a foods.recognized medical auth
trot ionfrom all be made
eal bred (optional),slice of note edit c
infant for use al
Breast m' as a finger food which are suitable lBorrarn STATE AGENCY info milk,provided b Y
infant formula from birth
in/ant's a AGREE THAT:
AND CENTER OR om
containing only breast ter infant's
ough '11 months
may be served in The cent use
of USDA
c F.
containing breast
milk
kmery dtoi a is qualify for of age However, meals maybe
n`SPer accountability, shall and Ponsib.
claimed f en components f month moot. Meals °oO1^9•shall y storage.accept full res
3. surinfhe purposep of
by the child caherre faciletl aascomponent or
storage have diversions, arid/or lossessrerovide a msul�s9 response t
g cup. this secTo tion, a cup means a standard mea- ed a center or sponsor solely shape o USDA commodity food:
this commodity foods sponsor and shall those persons 5
as follows: additional foods without prior written approval
otherwise di,
of the
neceoyfhat the information SIGNATURE
^ with the receipt
on this
Federal criminal Federal funds,is true N BENq�p
sfoaiof o F eana correct
m OF unds, and that t°the best o/
`--C-YL-[' p/? eratemisrepresenC°Nd9eRRSPONSOR
Signature --6—r" �"� ration may understand that
this a me Y subject me to prosecutionmation is under apbecableiven
Please �
p Sta
ase complete,sign,and return all 3 copies r.. P--ale
FOURTH MEAL DOCUMENT
Child care centers may claim 4 meals per child per day, if the
child is in care eight (8) or more hours each day. One of the 4
meals must be a snack.
In order to claim the 4th meal for an individual child, you must:
1. Keep Records of Meals Served for the 4th meal.
2 . Keep menu and production records for the 4th meal.
3 . Keep time-in/time-out records for the child.
4 . Apply for the 4th meal by completing the bottom of this
form and returning it to our office.
As you can see, it may be an extra burden of paperwork to you to
claim the 4th meal . And, although the 4th meal certainly may be
a supper, in most centers it will be a snack. Current reimburse-
ment for snacks is 44.25 cents for Free, 22 cents for Reduced,
and 4 cents for Paid. Therefore, the amount of reimbursement may
not be enough to cover the cost of the extra labor involved.
Also, during our reviews, we have found that many centers do not
have an accurate time-in/time-out record process. Either the
records are incomplete or they indicate that children in care
less than 8 hours are claimed for 4th meals. Because of this, we
had to take back a significant amount of reimbursement money
causing hardship to the centers. Therefore, someone must be
assigned to monitor these time-in/time-out records if you claim a
4th meal per child per day.
XX NO, a fourth meal will not be claimed.
YES, a fourth meal will be claimed. (One of the 4 meals
must be a snack. )
Type of meal
Time of meal
Effective date
YES, we keep time-in/time-out records.
Family Educational Network of Weld County
Name of Center or Sponsor
Signature f Authorized Representative Date
S11.0 Vim "
(CDH-CACFP 4/91)
AUDIT QUESTIONNA1AE
center Family Educational Network of Weld County Number, 08 65103
Ada= 520 13 Avenue,
Greeley, Colorado 80631
1. Do you have an audit done of your center? Yes X No
If so, is it an organization-wide audit? Yes X No
Is CACFP included in your organization-wide audit? Yes x No
The term "organization-wide audit" means an audit of all funds received by an organiza-
tion, inclusive of federal, state, local, and private funds. The audit must include a random
sampling of all federal funds received by the institution, and it must be conducted by an
independent auditor.
2. If yes,what is the correct name of the organization being audited? (For example,
Mile High Child Care)
Weld County
3. When does your center's fiscal year begin and end?
January 1 Hugh December 31
4. What federal funds does your center receive other than CACFP?
(For example, Title XX— S5,000)
Head Start — S = 650.000 on +
Migrant Head Start — S 650.000 00 +
— S
— S
5. What is the total annual budget for all programs in your organization (including all
federal,state, and "other" funds)?
$1,500,000.00
6. Does your center have fiscal year end schedules? Yes XX No
(finaticial statements)
7. Does your center have computerized records? Yes X.K No
Questionnaire prepared by: Tere Keller
Tine: Director Phone Number (3031355-Mon
Rev.6/90
TAXPAYER IDENTIFICATION NUMBER FORM
Pursuant to :eternal Revenue Service Regulations, vendors must furnish
their Taxpayer identification Number (-:N) to the State. If this number
is not provided, you may be subject to a 20» withholding on each payment.
To avoid this 20' withholding and to insure :hat acct-ate tax information
is reported to the internal Revenue Service_ and the State, please use
this form to provide the requested information.
Legal Business Name Weld County Division of Human Resources
Family Educational Network of Weld County
Address 520 13 Avenue
Greeley, Colorado
80631
9 Digit Taxpayer identi==---4on Number
Social Security Number -
- - - - - - - - --
Federal Employs.- =__..- -atton Number _84_ - 6_ 0_0_Q.8_ L 4_
Business 2esi_nation (Check one)
_ Sore Proprietorship
Estate / __st
.._-:oration
Ser•. _cs o-rcr t_ n
x Co a-7=en.: , No- "-
Other Tax Attcunt Numbers
State Sales and Use Tax Number
State Employers Withholding Tax *lumber
State Unemployment Tax *cumber
State Corporation :ncome .ax Number
Under penalties of perjury, : declare that : have examined this request
and to the best of my knowledge and belie:, it is true, co.____, and
complete.
Tere Keller Director
Name ,cr_nt or zypei __le CPrtnt or type)
( 303 ) 356-06D0
__.nature le__ 'ere=hone
COLORADO DEPARTMENT OF HEALTH
CHILD AND ADULT CARE FOOD PROGRAM
PREAWARD COMPLIANCE REVIEW
Center or Sponsor Name: Family Educational Network of Weld Agreement # 08 65103
County
The Colorado Department of Health,Child&Adult Care Food Program,is required to conduct a preaward civil rights com-
pliance review of centers or sponsors applying for CACFP participation. Please complete the following information.
1. ESTIMATE the racial/ethnic makeup of the population of the area to be served(approximate percentages).Sponsor
must combine this information for all centers.Usually this information can be obtained from the local school dis-
trict, Chamber of Commerce, Census Bureau, or Public Library.
3% American Indian or Alaskan Native 95% Hispanic (a person of Mexican, Puerto Rican, Cuban,
Central or South American,or other Spanish culture or
Asian or Pacific Islander origin, regardless of race)
Black (not of Hispanic origin) 2% White (not of Hispanic origin)
2. =COUNT the actual number of children by racial/ethnic makeup in your center(s)and indicate those figures here.
Sponsor must combine for all centers.
3% American Indian or Alaskan Native 95% Hispanic (a person of Mexican, Puerto Rican, Cuban,
Central or South American,or other Spanish culture or
Asian or Pacific Islander origin, regardless of race)
Black(not of Hispanic origin) 2% White (not of Hispanic origin)
3. What efforts will be used to assure that minority populations&grassroots organizations have an equal opportunity to
participate-or are informed about changes in the Program?
X Distribution of brochures of Program information at public locations
X Public service announcements in local newspaper, on radio, or on television (circle media type used)
X Paid advertisements in local newspapers
X Other. Please explain: Agency referrals
Did the items you checked above include the following nondiscrimination statement?Yes X No
USDA forbids discrimination because of race,color,national origin,age,sex,or handicap.Any person who believes he
or she has been discriminated against in any USDA-related activity should write immediately to the Secretary of
Agriculture, Washington, D.C. 20250.
4. Is membership in a specific organization required before children can be enrolled? Yes_ No X
If yes, please explain:
5. Have you ever been found to be in noncompliance of the Civil Rights laws by any federal agency?
•
Yes_ No X If yes, please explain:
"Visual identification may be used by centers or sponsor to determine the child's racial/ethnic category.A child may be included
in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging. Parents/
Guardians may be asked to identify the racial/ethnic group of their own child only after it has been explained,and they under-
stand 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.As new children are enrolled,you will need to deter-
mine their racial/ethnic background and keep this information in a confidential place.
��
SIGNATURE OF AD INISTRATOR OR AUTHORIZED REPRESENTATIVE DATE
S��
CACFP 102 (5/90) �J.�.l34.
COLORADO DEPARTMENT OF HEALTH CHILD AND ADULT CARE FOOD AGREEMENT NUMBER
PROGRAM 84 6000814
APPLICATION FOR CHILDCARE CENTER
I NSTRUCTIONS: Complete in duplicate.If a sponsored facility,the original(and required attachments)must be submitted with
CACFP 302 (Application for Sponsor of Child and Adult Care Centers): Type or print clearly.
1. NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 8. DO YOU CARE FOR CHILDREN IN SHIFTS? YES-. NO_
Greeley, Migrant Head Start
Shift care means that children are coming and going at all times of the-
520 13 Avenue day so that the total number of children attending the center on a daily
Greeley, CO A0631 356-0600 basis may exceed the license capacity.
TELEPHONE NO.: --
COUNTY: Weld 9. HOURS OF OPERATION
FROM 7:00 a.m. TO 4:00 p.m.
2. NAME AND TITLE OF PERSON RESPONSIBLE AT CENTER ,
Bessie Anthony 10.NUMBER OF OPERATING 11.NUMBER OF OPERATING
DAYS PER WEEK 5 WEEKS PER YEAR 20
3. TYPE OF FACILITY 12. ANNUAL DATES OF OPERATION -
NONPROFITCHILDCARECENTER - June10,199)ENDtNGSept.m Se 27 1991
OUTSIDE-SCHOOL-HOURS CENTER STARTING
FOR PROFIT TITLE XX CENTER(Must also submit 13. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
Agreement Addendum)
HEAD START PROGRAM AND SNACKS FOR REIMBURSEMENT(Include dates of closing and
reopening).
X MIGRANT HEAD START PROGRAM
NUMBER OF HEAD START CLASSROOMS:
AM ` 8 PM. 8
NUMBER OF CHILDREN IN EACH CLASSROOM varies 14. DO YOU NOW PARTICIPATE IN OR HAVE YOU PARTICIPATED IN
FEDERALLY-FUNDED PROGRAMS(INCLUDING CACFP AND
4. IS CENTER LICENSED OR APPROVED BY FEDERAL OR STATE NATIONAL SCHOOL LUNCH PROGRAM) IN THE PAST THREE
AUTHORITY', YES__X, NO YEARS? YES__X. _NO
(If"YES,"give name of Program(s)and dates of participation)
EXPIRATION DATE 8-11-88 CACFP from 19$5.
LICENSE CAPACITY 130
Is your Head Start 'site licensed as a child care center by the Colorado
Department of Social Services during times when Head.Start is not.In
session? YES rt NOS _
5. AGE RANGE OF ENROLLED CHILDREN -s:7: •-- 15. DO YOU PARTICIPATE-.IN THE COLORADO PRESCHOOLct..
FROM 6 Weeks To 5 years PROJECT? YES NO_ (not durina miarant)
18. IS THIS A PRIVATE ORGANIZATION?
12 MONTHS?
6. DO YOU CARE FOR INFANTS FROM BIRTH THROUGH YES NO non-governmental) .
("PRIVATE"means non-govemental) YES NO x
WILL YOU CLAIM THESE INFANTS ON THE CACFP? _ 17. IS CENTER SPONSORED?: YES"_X.t NO
If"YES,"give name of sponsor(Sponsor must submit CACFP 302)
7. IN YES NO YOU CARE FOR SPECIAL NEEDS CHILDREN/ :Weld County. Board Of. Commissioners
INFANTS ON A REGULAR BASIS? # ' :
WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE __ Weld Count Y. Division of Human Resources .,
18. IS THIS A PRICING OR NONPRICING PROGRAM?(Check one) PRICING(Please contact our office for further instruction 33141351)
• ''L'. '': S , X NONPRICING "
In a pricing program,centers establish a charge separate from tuition for mealsin order tothake up the dhference between the reimbursement provided by
the CACFP and the actual cost of serving.the meals. -.
In a nonpricing program,families pay a general tuition charge that covers all areas of child care service*proWded by the center,Including meals There is
no identifiable separate charge for meals, served to any children In care.
All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shall not exceed a typical month's rate of reimbursemem and shall be deducted from that month's claim for
reimbursement. -
19. CIVIL RIGHTS
PLEASE NOTE: If you are a single,independent center,complete the Preaward Compliance Review rather than this section.
PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS TRACT DATA
PUBLIC SCHOOL DATA, HOUSING AUTHORITY DATA, ETC. IN ADDITION, GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF. YOUR
CURRENT ENROLLMENT. a ' -
ESTIMATE '. ACTUAL
American Indian or Alaskan Native 3% 3%
Asian or Pacific Islander
Black(not of Hispanic origin)....:: ............. .... ......... ........ .... . . . -
Hispanic 'q5% 9F%
White(not of Hispanic 0691)..:...... . ..::...... ........ .:....... 2V 9°t.
CACFP-301 (5/90)
04 C
AM PM SUPPER
20. MEAL SERVED BREAKFAST SNACK LUNCH SNACK
TIME OF MEAL SERVICE(S) 7:30 y 11-11:30 3:00
NUMBER OF MEALS EXPECTED 13O 130
TO BE SERVED 130 "-
METHOD BY WHICH MEALS WILL BE PROVIDED: ARE Til�AL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT MEAL SERVICE LOCATION J�
PREPARATION AT CENTRAL KITCHEN YES NO�
_yr_UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM M
(SUBMIT COPY OF CONTRACT) ARE RECORD QF MEALS SERVED FORMS BEING KEPT FOR EACH
UNDER CONTRACT WITH FOOD SERVICE CATERER MEAL? YES_ NO
(SUBMIT COPY OF CONTRACT) -•
FOOD SERVICE STAFF PATTERN(Enter only personnel who will perform Child and Adult Care Food Program food service functions in this center.)
NUMBER Of YEARS
SPECIFIC CACFP FOOD
NAME OF POSITION NAME OF PERSON SERVICE DUTIES STAFF IN IN THIS
THIS POSITION POSITION
Cook Coordinate food service 12
Dorothy Searette 1
,.;' -
Cook aide to be hired distribute food & clean up •' 1 -
Teachers various persons serve food to the children 8 varies
asstist teachers 12 varies
teacher aides various persons ,
Director Tere Keller forms and reports •
1 2
,
<
L____-•
•
•
21. 1 CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE;THAT I WILL ACCEPT FINAL ADMINISTRA-
TIVE AND FINANCIAL RESPONSIBILITY FOR TOTAL CHILD 8 ADULT CARE FOOD PROGRAM OPERATIONS AT THIS CENTER IF NOT UNDER A
SPONSOR,THAT REIMBURSEMENT WILL BE CLAIMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;THAT DEPARTMENT OFFICIALS
MAY VERIFY INFORMATION;AND THAT DELIBERATE MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE
AND CRIMINAL STATUTES,AND THAT THE CACFP 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
MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL CRIMINAL STATUTES.
•
SIGNArE OF ADMINISTRATOR OR AUTHORIZED REPRESENTATIVE DATE
COLORADO DEPARTMENT OF HEALTH CHILD:AND-ADULT CARE-:FOOD; AGREEMENT NUMBER
PROGRAM 84 6000814
APPLICATION FOR CHILD CARE CENTER"
INSTRUCTIONS: Complete in du plicate.If a sponsored facility,the original(and required attachments)must be submitted with
CACFP 302 (Application for Sponsor of Child and. Adult Care Centers). Type or print clearly.
L NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 8, DO YOU CARE FOR CHILDREN IN SHIFTS'? YES_ . NO
Frederick, Migrant Head Start' Shift care means that children are coming and going at all times of the
340 Maple e day so that the total number of children attending the center on a daily
Q�{Q p basis may exceed the license capacity. _
TErErPt`�N -4,( CO .80530 (303)833-2230
COUNTY: Wej d : 9. HOURS OF OPERATION
FROM 7:00 am:°-- TO'i4:00pm ,
2. NAME AND TITLE OF PERSON RESPONSIBLE AT CENTER Agnes Martinez 10.NUMBER
WEEK s-OPERATLING it /('�G
WEEKS PER YEAR 4U
3. TYPE OF FACILITY • 12. ANNUAL DATES OF OPERATION
NONPROFIT CHILD CARE CENTER 'June'-10,. 199
OUTSIDE-SCHOOL-HOURS CENTER STARTING ENDING Sept. ZJ. 1991
FOR PROFIT TITLE XX CENTER(Must also submit
Agreement Addendum) 13. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
HEAD START PROGRAM - AND SNACKS FOR REIMBURSEMENT(Include dates of closing and
reopening).:.
XX MIGRANT HEAD START PROGRAM
NUMBER OF HEAD START CLASSROOMS: _
AM 4 PM 4
NUMBER OF CHILDREN IN EACH CLASSROOM yar PS ...14, DO YOU NOW PARTICIPATE IN OR HAVE YOU PARTICIPATED IN-
FEDERALLY-FUNDED PROGRAMS(INCLUDING CACFP AND
NATIONAL SCH
4. IS CENTER LICENSED OR APPROVED BY FEDERAL OR STATE LUNCH PROGRAM) IN THE-,PAST THREE
L.
E
AUTHORITY? YESX__ NO YEARS? YES_. _NO
Mdy 23, 1989 (It"YES give name of Program(s)and dates of participation)
EXPIRATION DATE
LICENSE CAPACITY 6n CACFP from 1985
Is your Head Start Site licensed as a child care center by.the Colorado
Department of Social Services during.times when Head Start is not in
5. AGE RANGE OF ENROLLED CHILDREN 15:DO YOU PARTICIPATE IN THE COLORADO PRESCHOOL:.
PROJECT? VESA ., __ not during migrant)
FROM 6 weeks- Tc 5 year
16. IS THIS A PRIVATE ORGANIZATION?
6. DO YOU CARE FOR INFANTS FROM BIRTH THROUGH YES NO
X : ("PRIVATE" non-govemmentap YES_ NO
12 MONTH57S,
WILL YOU CLAIM THESE INFANTS ON THE CACFP? _. 17:IS CENTER SPONSORED? YES . NO_
.4 If."YES,"give name of sponsor(sponsor must submit CACFP 302).,
7. DO YOU CARE FOR SPECIAL NEEDS CHILDREN/ YES NO
INFANTS ON A REGULAR BASIS? X _ Weld County:.Board of Commissioners .
WILL YOU CLAIM THESE..CHILDREN/INFANTS ON THE .. ---X.: Weld County,Division of. Human Resources
CACFP? ... _, rt .;-. `, �. ,. - * .•. '
18. IS THIS A PRICING OR NONPRICING,PROGRAM?(Check one) _PRICING(Please contact our office for further Instruction 331.8351)
'!1,2` .X:NONPRICING.. ^ . .
in a pricing program,centers establish a charge separate from tuition or meals in order to make up the difference between the reimbursement provided by
the CACFP and the actual cost of serving the meets " ` "
In a nonpricing program,families pay general tuition charge that covers all areas of child Caro services provided by the center,including meals:There is
no identifiable separate charge for meals served to any children in carer - -
All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shall not exceed a typical month's rate of reimbursement and shell be deducted from that month's claim for,:
reimbursement
PLEASE NOTE: If you are a single, independent center,complete the Preaward Compliance Review rather than this section. -
PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS TRACT DATA,
PUBLIC SCHOOL DATA, HOUSING.AUTHORITY DATA, ETC. IN-ADDITION,. GIVE THE°ACTUAL.RACIAL/ETHNIC BREAKDOWN OF. YOUR.
- CURRENT ENROLLMENT. -
)"
American Indian or Alaskan Native. . ..
Asian or Pacific islander................ :. ....... .Y'.......
Hispanic. ..::.:... ...:::.:. .....:.. :........ ' :...... :�,.... . .:. : ...... ` 95% - 95%
White(not of Hispanic origin)....... ...... .:......... i......... 2%" ,. 2% • � -
CACFP-301 (5/90) ? Pi
AM PM
20. MEAL SERVED _ BREAKFAST SNACK LUNCH • SNACK SUPPER
TIME OF MEAL SERVICE(S) 11-11 3� 3:00
7:30 --
NUMBER OF MEALS EXPECTED
TO BE SERVED 60 60
METHOD BY WHICH MEALS WILL BE PROVIDED:
PREPARATION AT MEAL SERVICE LOCATION ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT CENTRAL KITCHEN YES_ NO_
•
XX UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM
(SUBMIT COPY OF CONTRACT) ARE RECORD OF MEALS SERVED FORMS BEING KEPT FOR EACH
UNDER CONTRACT WITH FOOD SERVICE CATERER MEAL? YES_ NO
(SUBMIT COPY OF CONTRACT)
FOOD SERVICE STAFF PATTERN(Enter only personnel who will perform Child and Adult Care Food Program food service functions in this center.)
SPECIFIC CACFP FOOD NUMBER OF YEARS
NAME OF POSITION NAME OF PERSON SERVICE DUTIES STAFF IN IN THIS
THIS POSITION POSITION
•
cook aide to be hired distribute food and clean 1 -
teachers various persons serve food to the children 4 varies
teacher aides various persons assist .teachers 6 varies
site supervisor ;Agnes Martinez reports and-paper work 1 1
21. 1 CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE;THAT l WILL ACCEPT FINAL ADMINISTRA-
TIVE AND FINANCIAL RESPONSIBILITY FOR TOTAL CHILD&ADULT CARE FOOD PROGRAM OPERATIONS AT THIS CENTER IF NOT UNDER A
SPONSOR,THAT REIMBURSEMENT WILL BE CLAIMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;THAT DEPARTMENT OFFICIALS
MAY VERIFY INFORMATION;AND THAT DELIBERATE MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE
AND CRIMINAL STATUTES,AND THAT THE CACFP 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
MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL CRIMINAL STATUTES.
1 t o_
SIGN TURE OF ADMINISTRATOR OR AUTHORIZED REPRESENTATIVE DATE
d 14' 4
COLORADO DEPARTMENT OF HEALTH CHILD AND ADULT CARE FOOD AGREEMENT NUMBER
PROGRAM
APPLICATION FOR CHILD CARE CENTER 84 6000814
INSTRUCTIONS: Complete in duplicate.If a sponsored facility,.the original(and required attachments)must be submitted with
CACFP 302 (Application for Sponsor of Child and Adult Care Centers). Type or print clearly.
1. NAME AND ADDRESS OF CENTER(FEEDING LOCATION) ,8. DO YOU CARE FOR CHILDREN IN SHIFTS? YES-. NO .
Fort Collins , ..Migrant Head Start : Shift care means that children are coming and going at all times of the
5400 Mail Creek Lane day so that the total number of children attending the center on a daily
FF rr11 }} ((``� basis may exceed the Ifoense capacity.
TELEPHONE`NO� l 1 n S , ) CO
COUNTY: -9. HOURS OF OPERATION
FROM 7 :3 0 TO'4: O 0
2. NAME AND TITLE OF PERSON RESPONSIBLE AT CENTER
Pat Sandoval, Site ery SU iSor 10.NUMBER OF OPERATING 11.NUMBER OF OPERATING
Supervisor DAYS PER WEEK ! WEEKS PER YEAR 1.0 -
3. TYPE OF FACILITY 12. ANNUAL DATES OF OPERATION
NONPROFIT CHILD CARE CENTER - STARTING June 10 , 191 i4bING Sept 77
OUTSIDE-SCHOOL-HOURS CENTER
FOR PROFIT TITLE.XX CENTER(Must also submit
Agreement Addendum) 13. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
HEAD START PROGRAM AND SNACKS FOR REIMBURSEMENT(Include dates of closing and
reopening).
X MIGRANT HEAD START PROGRAM
NUMBER OF HEAD START CLASSROOMS:
AM 3 PM 3
NUMBER OF CHILDREN IN EACH CLASSROOM va ri eS14. DO YOU NOW PARTICIPATE IN OR HAVE YOU PARTICIPATED IN
FEDERALLY-FUNDED PROGRAMS(INCLUDING CACFP AND
4. IS CENTER LICENSED OR APPROVED BY FEDERAL OR STATE NATIONAL SCHOOL LUNCH PROGRAM) IN THE .PAST THREE
AUTHORITY? YES,:- NO-X-. pending YEARS? YES X —NO
(If"YES,"give name of Program(s)and dates of participation)
EXPIRATION DATE •
LICENSE CAPACITY • - CACFP since . 1985
Is your Head Start site licensed as a child care center by the Colorado
Department of Social Services during times when Head.Start is not in -
- session?
5. AGE RANGE OF ENROLLED CHILDREN 15. DO YOU PARTICIPATE IN THE COLORADO PRESCHOOL',,
PROJECT? YES NO not during migrant
FROM 6 Wppkc TO years
6. DO YOU CARE FOR INFANTS FROM BIRTH THROUGH YES NO 16. IS THIS A P ORGANIZATION?: ("PRIVATE"meansRIVATE non-governmental) X
YES— NO__12 MONTHS? X -
WILL YOU CLAIM THESE INFANTS ON THE CACFP? 17. IS CENTER SPONSORED? YES X NO
If"YES,"give name of sponsor(Sponsor must submit CACFP 302).
7. DO YOU CARE FOR SPECIAL NEEDS CHILDREN/ YES.. NO Weld of Commissioners
INFANTS ON A REGULAR BASIS? X Weld Count Division of Human resources
WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE y
t& IS THIS A PRICING OR NONPRICING PROGRAM?(Check one) :PRICING(Please contact our office for further instruction 331-8351)
YNONPRICING .
In a pricing program,centers establish a charge separate from tuition for meals in order to make up the difference between the reimbursement provided by
the CACFP and the actual cost of serving the meals ( - `-:
In a nonpncing program,families pay a general tuition charge that covers all areas of child care services provided by the center,including meals There is
no identifiable separate charge for meals, served to any children in care. .
All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money,shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for
reimbursement. -
19. CIVIL RIGHTS •
PLEASE NOTE: If you are a single, independent center,complete the Preaward Compliance Review rather than this section.
PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS TRACT DATA,
PUBLIC SCHOOL DATA, HOUSING AUTHORITY DATA ETC..IN ADDITION, GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR
CURRENT ENROLLMENT.
ESTIMATE` ACTUAL
American Indian or Alaskan Native ' 2'S Q
.- Asian or Pacific Islander
Black(not of.Hispanic origin)
Hispanic - 98% ' 100%
White(not of Hispanic origin)
CACFP-301 (5/90) O1.v of-;a,-. _.
AM PM SUPPER
20. MEAL SERVED BREAKFAST SNACK LUNCH SNACK
TIME OF MEAL SERVICE(S) 8: 00 _ 11 : 00 3:00
NUMBER OF MEALS EXPECTED 30 30
TO BE SERVED 30
METHOD BY WHICH MEALS WILL BE PROVIDED: ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
_PREPARATION AT MEAL SERVICE LOCATION
PREPARATION AT CENTRAL KITCHEN YES X NO._
X UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM ,
(SUBMIT COPY OF CONTRACT) ARE RECORD Qf MEALS SERVED FORMS BEING KEPT FOR EACH
UNDER CONTRACT WITH FOOD SERVICE CATERER MEAL? YES NO
(SUBMIT COPY OF CONTRACT)
FOOD SERVICE STAFF PATTERN (Enter only personnel who will perform Child and Adult Care Food Program/ood service functions in this center.)
T
SPECIFIC CACFP FOOD NUMBER OF YEARS
NAME OF POSITION NAME OF PERSON • SERVICE DUTIES STAFF IN IN THIS
THIS POSITION POSITION
cook aide to be hired distribute and clean 1 -
teachers various persons serve food to children 3 varies
teacher aides various persons assist teachers
5 varies
site superviso - Pat Sandoval reports and paper work 1 1
21. I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE;THAT 1 WILL ACCEPT FINAL ADMINISTRA-
TIVERESPONSIBILITY FOR TOTAL CHILD&ADULT CARE
NS AT THIS CENTER IF NOT UNDER A
SPONSOR,THAT REIMBURSEMENT WILL BE CL O
AIMED ONLY FOR MEALS SERVED T IL
O ENROLD PROGRAM LED CHILDREN;THAT DEPARTMENT OFFICALS
MAY VERIFY INFORMATION;AND THAT DELIBERATE MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE
AND CRIMINAL STATUTES,AND THAT THE CACFP 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
MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL CRIMINAL STATUTES.
,x--c-e f"�� DATE
SI NATURE OF ADMINISTRATOR OR AUTHORIZED REPRESENTATIVE
COLORADO DEPARTMENT OF HEALTH CHILD AND ADULT CARE FOOD AGREEMENT NUMBER
PROGRAM 84 6000814
APPLICATION FOR CHILD CARE CENTER
INSTRUCTIONS: Complete in duplicate.If a sponsored facility,the original(and required attachments)must be submitted with
CACFP 302 (Application for Sponsor of Child and Adult Care Centers). Type or print clearly.
1. NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 8. DO YOU CARE FOR CHILDREN IN SHIFTS? YES— NO_X_
Brighton, Migrant Head Start Shift care means that children are coming and going at all times of the
675 EhNOg bert day so that the total number of children attending the center on a daily
ONE , CO basis may exceed the license capacity.
TEL rl PH
9. HOURS OF OPERATION
COUNTY: Adams
FROM 7:00am To 4:00pm
2. NAME AND TITLE OF PERSON RESPONSIBLE AT CENTER
Dorothy Perez 10.NUMBER OF OPERATING 11.NUMBER OF OPERATING
DAYS PER WEEK 5 WEEKS PER YEAR 20
3. TYPE OF FACILITY 12. ANNUAL DATES OF OPERATION
NONPROFIT CHILD CARE CENTER STARTING June 10, 19&DIZ.ept 27, 1991
OUTSIDE-SCHOOL-HOURS CENTER
FOR PROFIT TITLE XX CENTER (Must also submit
Agreement Addendum) 13. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
AND SNACKS FOR REIMBURSEMENT(Include dates of closing and
HEAD START PROGRAM reopening).
XX MIGRANT HEAD START PROGRAM
NUMBER OF HEAD START CLASSROOMS:
AM 4 PM 4
NUMBER OF CHILDREN IN EACH CLASSROOM varies 14' DO YOU NOW PARTICIPATE DERALLY-UNDED P OR U TED
PROGRAMS (INCLUDING CACFPI AND
IN
ND
NATIONAL SCHOOL LUNCH PROGRAM) IN THE PAST THREE
4. IS CENTER LICENSED OR APPROVED BY FEDERAL OR STATE
YEARS? YES_2(_ _NO
AUTHORITY? YES_ NO
-X— (If "YES"give name of Programs) and dates of participation)
EXPIRATION DATE
LICENSE CAPACITY •
CACFP since 1985
Is your Head Start site licensed as a child care center by the Colorado
Department of Social Services during times when Head Start is not in
session?
YES_ NO p
5. AGE RANGE OF ENROLLED CHILDREN 15. DO YOU PARTICIPATE INNOHE COLORADO
L°dPRESCHOOL
u r i n°g°Lmigrant
FROM 6 weeks TO 5 years Il
NO 16. IS THIS A PRIVATE ORGANIZATION?
6. DO YOU CARE FOR INFANTS FROM BIRTH THROUGH YES (^pRI VATE"means nongovernmental) YES_ NO
12 MONTHS?
WILL YOU CLAIM THESE INFANTS ON THE CACFP? — _ 17. IS CENTER SPONSORED? YES X. NO
If "YES:"give name of sponsor(Sponsor must submit CACFP 302).
7. DO YOU CARE FOR SPECIAL NEEDS CHILDREN/ YES NO
INFANTS ON A REGULAR BASIS? - Weld County Board of Commissioners
WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE — Weld County Division of Human Resour_e.
CACFP?
18. IS THIS A PRICING OR NONPRICING PROGRAM? (Check one) — PRICING (Please contact our office for further instruction 331-0351)
NONPRICING
In a pricing program,centers establish a charge separate from tuition for meals in order to make up the difference between the reimbursement provided by
the CACFP and the actual cost of serving the meals.
In a nonpricing program,families pay a general tuition charge that covers all areas of child care services provided by the center,including meals.There is
no identifiable separate charge for meals, served to any children in care.
All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The
amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for
reimbursement.
19. CIVIL RIGHTS
PLEASE NOTE: If you are a single, independent center,complete the Preaward Compliance Review rather than this section.
PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS TRACT DATA.
PUBLIC SCHOOL DATA. HOUSING AUTHORITY DATA, ETC. IN ADDITION, GIVE THE ACTUAL RACIAUETHNIC BREAKDOWN OF YOUR
CURRENT ENROLLMENT.
ESTIMATE ACTUAL
American Indian or Alaskan Native -
Asian or Pacific Islander
Black(not of Hispanic origin) 10U70 7 1 D U o
Hispanic
White(not of Hispanic origin)
CACFP-30115/901 t?;�
AM PM SUPPER
20. MEAL SERVED BREAKFAST SNACK LUNCH SNACK
TIME OF MEAL SERVICE(S) 7 : 30 11 : 00 2 : 30
J
NUMBER OF MEALS EXPECTED 50 50 50
TO BE SERVED _
METHOD BY WHICH MEALS WILL BE PROVIDED: ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
PREPARATION AT MEAL SERVICE LOCATION
PREPARATION AT CENTRAL KITCHEN YES. X_ NO�
X UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM
(SUBMIT COPY OF CONTRACT) ARE RECORD OF MEALS SERVED FORMS BEING KEPT FOR EACH
UNDER CONTRACT WITH FOOD SERVICE CATERER MEAL? YES_)S NO
(SUBMIT COPY OF CONTRACT) -
FOOD SERVICE STAFF PATTERN (Enter only personnel who will perform Child and Adult Care Food Program food service functions in this center.)
SPECIFIC CACFP FOOD NUMBER OF YEARS
SERVICE DUTIES STAFF IN IN THIS
NAME OF POSITION NAME OF PERSON THIS POSITION POSITION
cook aide to be hexed distribute and clean 1 -
teachers various persons serve food to children 4 . varies
teacher aides various persons assist teachers 7 varies
site supervisor Dorothy Perez reports and paper work 1 1
.. .
I
21. I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE;THAT I WILL ACCEPT FINAL ADMINISTRA-
TIVE AND FINANCIAL RESPONSIBILITY FOR TOTAL CHILD&ADULT CARE FOOD PROGRAM OPERATIONS AT THIS CENTER IF NOT UNDER A
SPONSOR,THAT REIMBURSEMENT WILL BE CLAIMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;THAT DEPARTMENT OFFICIALS
MAY VERIFY INFORMATION;AND THAT DELIBERATE MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE
AND CRIMINAL STATUTES,AND THAT THE CACFP 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
MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL CRIMINAL STATUTES.
r.C_..L._ .a_ L_L_ i
SIGNATURE OF ADMINISTRATOR OR AUTHORIZED REPRESENTATIVE DATE
J
COLORADO DEPARTMENT OF'HEALTH CHILD.AND ADULT CARE-FOOD- AGREEMENT NUMBER '
PROGRAM
APPLICATION FOR CHILD CARE CENTER " sa 6000814
INSTRUCTIONS: Complete in duplicate.If a sponsored facility,the original(and required attachments)must be submitted with
CACFP 302 (Application for Sponsor of Chitd and Adult Care Centers)..Type or print clearly.
1. NAME AND ADDRESS OF CENTER (FEEDING LOCATION). X
8. DO YOU CARE FOR CHILDREN IN SHIFTS? YES _, NO—
Fort Morgan , .Migrant 1-lead_S tart Shift care means that Children are coming and going at all times of the•<
i3 0 0 Lake Street - day so that Me total number of children attending the center on a daily
F pp pp r 9 a n s 1 C D 80701'
basis may exceed the license CePacity.
TELE HO E O..
COUNTY: Morgan 9. HOURS OF OPERATION
FROM-"7 : 30'' ' TG'4: 00
2. NAME AND TITLE OF PERSON RESPONSIBLE AT CENTER
Susan Guzman 10.NUMBER OF OPERATING 11.NUMBER OF 6PERAT1NG
DAYS PER WEEK 3 WEEKS.PER YEAR 1.0
3. TYPE OF FACILITY
12. ANNUAL DATES OF:OPERATION
NONPROFIT CHILD CARE CENTER L.
OUTSIDE-SCHOOL-HOURS CENTER STARTING ENDING
FOR PROFIT TITLE XX CENTER(Must also submit •
Agreement Addendum) 13. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS
HEAD START PROGRAM AND SNACKS FOR REIMBURSEMENT(Include dates of closing and
reopening).
X MIGRANT HEAD START PROGRAM
NUMBER OF HEAD START CLASSROOMS: -
"AM PM__.3.__
NUMBER OF CHILDREN IN EACH CLASSROOM V a r i e g 14. DO YOU NOW PARTICIPATE IN OR HAVE YOU PARTICIPATED.IN
FEDERALLY-FUNDED PROGRAMS(INCLUDING CACFP AND
4. IS CENTER LICENSED OR APPROVED B1( FEDERAL OR STATE NATIONAL SCHOOL LUNCH PROGRAM) IN THE PAST THREE .
AUTHORITY? YES_ NO X pending YEARS? . .YES X_. NO.'
(If"YES'give name of Program(s)and dates of participation)
EXPIRATION DATE _
LICENSE CAPACITY CACFP since ..1985
Is your Head Start site licensed as a child care center by the Colorado 'z.y
Department of Social Services during times.when Head Start is not in .;.
session?
' 5. AGE RANGE OF ENROLLED CHILDREN 15. DO YOU PARTICIPATE IN THE COLORADO PRESCHOOL' •
• PROJECT? YESX._.-. NO— Not duri ng' migrant
FROM 6 weeks TO`.. 5' years
6. DO YOU CARE FOR INFANTS FROM BIRTH THROUGH YES NO 18. IS THIS A PRIVATE ORGANIZATION? X •
� ,.
12 MONTHS? ("PRIVATE'•means non•govemmental) YES— NO '
WILL YOU CLAIM THESE INFANTS ON THE CACFP, —x,:.— _.17. IS CENTER SPONSORED? YES X NO
"YES"give name of sponsor(Sponsor must submit CACFP 302).
7. DO YOU CARE FOR SPECIAL NEEDS CHILDREN/ YES NO Weld County; Board of Commissioners
INFANTS ON AREGULAR BASIS? • —X — Weld County Division 0f. ' Human: Resource
WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE - •
18. IS THIS A PRICING OR NONPRICING PROGRAM?(Check one) :PRICING(Please contact our office for further Instruction 3314351)
• �. —NONPRICING o .'.
In a pricing program,centers establish a charge separate from tuition for meals in order to make up the difference between the reimbursement provided by
the CACFP and the actual cost of serving the meals .. -t„ -7. _ 4
In a nonpocing program,families pay a genial tuition charge that covers all areas of chHd care services provided by the center,including meals.There is
no identifiable separate charge for meals,served to any children in care. "k,..'=All participating centers or sponsors are eligible to receive advance payments.Advances are requested monthly by filling out an advance form.The.
amount of advance money shall not exceed atypical month's rate of reimbursement and shall be.deducted from that month's claim for
reimbursement
19. CIVIL RIGHTS •„}R �:�"'
PLEASE NOTE: If you are a single:independent center,complete the Preaward Compliance Review rather than this section.
PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS TRACT DATA,
PUBLIC SCHOOL DATA, HOUSING AUTHORITY- DATA, ETC. IN ADDITION, GIVE THE ACTUAL..RACIAL/ETHNIC BREAKDOWN OF YOUR
CURRENT ENROLLMENT. k <;,. ,. , -
,tx
American Indian or Alaskan Native...... _"' '
Asian or Pacific Islander.....,. "
Black(not of Hispanic origin)
;....r: 100% 100%Hispanic.. .......: .. . .:... .. .. _ .
`CACFP-30115/90) '• • , gnu..- '
fit•'� ��';'f a^•*r '?
AM 'PM SUPPER
20. MEAL SERVED BREAKFAST SNACK LUNCH SNACK
TIME OF MEAL SERVICE(S) 7: 45 11 : 30 2: 30
NUMBER OF MEALS EXPECTED •
3 0 30
TO BE SERVED 30
i
METHOD BY WHICH MEALS WILL BE PROVIDED:
PREPARATION AT MEAL SERVICE LOCATION ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL?
X
PREPARATION AT CENTRAL KITCHEN YES NO
M UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM •
(SUBMIT COPY OF CONTRACT) ARE RECORD OF MEALS SERVED FORMS BEING KEPT FOR EACH
UNDER CONTRACT WITH FOOD SERVICE CATERER MEAL? YES_X NO
(SUBMIT COPY OF CONTRACT)
FOOD SERVICE STAFF PATTERN(Enter only personnel who will perform Child and Adult Care Food Program food service functions in this center.)
SPECIFIC CACFP FOOD NUMBER OF YEARS
NAME OF POSITION NAME OF PERSON • SERVICE DUTIES STAFF IN IN THIS
THIS POSITION POSITION
cook aide to be hired distribute and clean 1 -
teachers various serve food to children 3 varies
teacher aides various assist teachers 5 varies
site superviso^ Susan Guzman reports and paper:work 1 -
•
•
•
21. I CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE:THAT I WILL ACCEPT FINAL ADMINISTRA-
TIVE AND FINANCIAL RESPONSIBILITY FOR TOTAL CHILD 6 ADULT CARE FOOD PROGRAM OPERATIONS AT THIS CENTER IF NOT UNDER A
SPONSOR,THAT REIMBURSEMENT WILL BE CLAIMED ONLY FOR MEALS SERVED TO ENROLLED CHILDREN;THAT DEPARTMENT OFFICIALS
MAY VERIFY INFORMATION;AND THAT DELIBERATE MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE
AND CRIMINAL STATUTES,AND THAT THE CACFP WILL BE AVAILABLE TO ALL ELIGIBLE CHILDREN REGARDLESS OF RACE,COLOR,NATIONAL.
ORIGIN,SEX, HANDICAP,OR AGE.
1 UNDERSTAND THAT THIS INFORMATION IS BEING GIVEN IN CONNECTION WITH THE RECEIPT OF FEDERAL FUNDS,AND THAT A DELIBERATE
MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL.CRIMINAL STATUTES.
r
SIGN URE OF ADMINISTRATOR OR AUTHORIZED REPRESENTATIVE DATE
r Z. •
-
COLORADO DEPARTMENT OF HEALTH
CHILD AND ADULT CARE FOOD PROGRAM 84 6000814
Agreement #
CHILD CARE CENTER
NONDISCRIMINATION POLICY STATEMENT
NONPRICING CENTER OR SPONSOR
1.
Family Educational Network of Weld County assures the Colorado Department
(Name of Center or Sponeorl
of Health, Child and Adult Care Food Program, that all enrolled children participating in the Child &Adult Care
Food Program at the centers 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 there is no discrimination in the course of the
meal service. -
2. CHECK ONE
�( (RENEWING CENTER OR SPONSOR)
We have submitted a Press Release (sample on reverse side)to the news media(radio, television,or other)
serving the area(s)from which our center or sponsor draws attendance announcing the availability of meals at
no separate charge to enrolled children.
❑ (NEW CENTER OR SPONSOR)
We will annually submit a Press Release(please use the sample Public Service Announcement Press Release
on the reverse side)to the news media(radio,television,or other)serving the area(s)from which our center or
sponsor draws attendance announcing the availability of meals at no separate charge to enrolled
children.
3. We understand that we are not required by the Colorado Department of Health,Child&Adult Care Food Program
to pay for publication of our Press Release.If the Press Release is sent in a form other than as a Public Service
Announcement, you may be required to pay for it.
4. We will retain a copy of the Press Release sent to the media in our permanent files.
5. We have included or will send a copy of the Press Release that was sent to be published or aired indicating to
whom it was sent and the date it was sent
6. We have collected actual racial/ethnic data for each child presently enrolled and have included it on the Preaward
-Compliance Review form.We understand that the collection of this information is strictly for statistical reporting
requirements and has no effect on the determination of the eligibility of children to receive benefits under
the Program.
fa.Xeel
Si nature of Administrator Date
or
Authorized Representative
Administrator
Signature of Official of the Title Date
Colorado Department of Health,
Child & Adult Care Food Program
• 01 P.-
CACFP 303N (5/90)
PUBLIC SERVICE ANNOUNCEMENT
PRESS RELEASE (a Public Service Announcement regarding participation in the Colorado Department of Health's
Child & Adult Care Food Program)
The Family Fdurational Network of Wald County intends to sponsor the Child&
(Name of Center or Sponsor)
Adult Care Food Program.The same meals will be made available to all enrolled children participating in the Child&
Adult Care Food Program,at no separate charge regardless of race,color,national origin,age,sex,or handicap,and
there is no discrimination in the course of the meal service. If you believe that you have been treated unfairly in
receiving food services for any of these reasons, write immediately to the Secretary of Agriculture, Washington,
D.C. 20250.
Eligibility for free and reduced meal reimbursement is based on the following income scales effective July 1, 1990
through June 30, 1991.
Annual Income
Family Size Free Meals Reduced Meals
1 8,164 11,618
2 10,946 15,577
3 13,728 19,536
4 16,510 23,495
5 19,292 27,454
6 22,074 31,413
7 24,856 35,372
8 27,638 39,331
For each additional
family member add: 2,782 3,959
Name, Address, Telephone Number and Contact Person of Each Center: ,
Tere' Keller:, _520 13 Ave . , Greeley 80631 ( 303 ) 356-0600
Agnes Martinez , 340 Maple , Frederick ,80530 ( 303 ) 833-2230
.Dorothy Perez , 675 Egbert , Brighton 80601
Pat Sandoval , 5400 Mail Creek Ln . 80525
Susan Guzman , 300 Lake St. 80701
Local newspapers and radio stations
Press Release Sent To:
Date Sent: will hP Sant 6-7-91
COLORADO DEPARTMENT OF HEALTH
CHILD AND ADULT CARE FOOD PROGRAM gq 6000814
Agreement #
CHILD CARE CENTER
NONDISCRIMINATION POLICY STATEMENT
NONPRICING CENTER OR SPONSOR
1. Family Educational Network of Weld County assures the Colorado Department
(Name of Center or Sponsor
of Health, Child and Adult Care Food Program,that all enrolled children participating in the Child &Adult Care
Food Program at the centers 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 there is no discrimination in the course of the
meal service.
2. CHECK ONE
;i (RENEWING CENTER OR SPONSOR)
We have submitted a Press Release (sample on reverse side)to the news media (radio,television,or other)
serving the area(s)from which our center or sponsor draws attendance announcing the availability of meals at
no separate charge to enrolled children.
❑ (NEW CENTER OR SPONSOR)
We will annually submit a Press Release(please use the sample Public Service Announcement Press Release
on the reverse side)to the news media(radio,television,or other)serving the area(s)from which our center or
sponsor draws attendance announcing the availability of meals at no separate charge to enrolled
children. •
3. We understand that we are not required by the Colorado Department of Health,Child&Adult Care Food Program
to pay for publication of our Press Release.If the Press Release is sent in a form other than as a Public Service
Announcement, you may be required to pay for it. •
•
4. We will retain a copy of the Press Release sent to the media in our permanent files.
5. We have included or will send a copy of the Press Release that was sent to be published or aired Indicating to
whom it was sent and the date it was sent
6. We have collected actual racial/ethnic data for each child presently enrolled and have included it on the Preaward
Compliance Review form.We understand that the collection of this information is strictly for statistical reporting
requirements and has no effect on the determination of the eligibility of children to receive benefits under
the Program.
Sigrtature of Administrator Date
or
Authorized Representative
Administrator _
Signature of Official of the Title Date
Colorado Department of Health,
Child & Adult Care Food Program
e -1 ra •i;,
CACFP 303N (5/90)
PUBLIC SERVICE ANNOUNCEMENT
PRESS RELEASE (a Public Service Announcement regarding participation in the Colorado Department of Health's
Child & Adult Care Food Program)
The Family Educational Network of Weld County intends to sponsor the Child&
(Name of Center or Sponsor)
Adult Care Food Program.The same meals will be made available to all enrolled children participating in the Child&
Adult Care Food Program,at no separate charge regardless of race,color,national origin,age,sex,or handicap,and
there is no discrimination in the course of the meal service. If you believe that you have been treated unfairly in
receiving food services for any of these reasons, write immediately to the Secretary of Agriculture, Washington,
D.C. 20250.
Eligibility for free and reduced meal reimbursement is based on the following income scales effective July 1, 1990
through June 30, 1991.
Annual Income
Family Size Free Meals Reduced Meals
1 8,164 11,618
2 10,946 15,577
3 13,728 19,536
4 16,510 23,495
5 19,292 27,454
6 22,074 31,413
7 24,856 35,372
8 27,638 39,331
For each additional
family member add: 2,782 3,959
Name, Address, Telephone Number and Contact Person of Each Center:
Tere Keller, 520 13 Avenue . , Greeley 80631 ( 303 ) 356-0600
Agnes Martinez , 340 Maple . , Frederick 80530 ( 303 ) 833-2230
Dorothy Perez , 675 Egbert , Brighton 80601
Pat Sandoval , 5400 Mail Creek Ln . , Fort Collins 80525
Susan Guzman , 300 Lake St . , Fort Morgan 80701
local newpapers and radio stations
Press Release Sent To: —
Date Sent: will be sent 6-7-41
COLORADO DEPARTMENT OF HEALTH
CHILD AND ADULT CARE FOOD PROGRAM
DONATED FOODS (COMMODITIES) ADDENDUM
Center or Sponsor Name: Family Educational Network Agreements 84 6000814
The USDA Donated Foods (Commodities) Program in Colorado is administered by the Colorado Department of
Social Services.The role of the Colorado Department of Health Child and Adult Care Food Program is limited to the
following duties:
1. Explain the choice of donated foods to centers or sponsors. (There are two choices).
2. Report the choice of donated foods by centers or sponsors to the Colorado Department of Social
Services.
3. Reimburse centers or sponsor according to choice of donated foods.
4. Assist in. monitoring the proper distribution, storage. and use of donated foods during site reviews or
visits.
The two choices for donated foods are: (1) regular donated commodities.or(2)cash-in-lieu of commodities.Regard-
less of choice,you will receive monetary reimbursement for allowable meals served to children. Rates of reimburse-
ment vary according to meal type,income category,and choice of donated foods.Please refer to your current rates of
reimbursement.
Choosing regular donated commodities entitles you to receive various canned,frozen, and dry foods depending on
what USDA purchases for the year in addition to the regular meal reimbursement.
Choosing cash-in-lieu of commodities entitles you to receive 1 = cents more reimbursement for every lunch or sup-
per that you claim.
Every soring a survey is mailed to all Child and Adult Care Food Program centers or sponsors.At this time,you make
the choice of donated foods for the next commodity year,which begins July 1.This choice cannot be cnanoed until
the next spring survey. PLEASE NOTE: If you enter the Child & Adult Care Fooa Program other than curing the
spring survey, you can only receive casn-in-lieu or commoaities.
The Colorado Department of Social Services will send you a donated foods packet including an order form after we.
the Colorado Department of Health Child&Adult Care Food Program,inform them of your participation and choice of
donated foods.
By signing this addendum,you are indicating that you understand its contents. If you completed the spring survey
your choice is indicated below. If you are a new Program participant, you must indicate the cash-in-lieu
choice.
The center or sponor will receive:
DI Regular donated commodities
❑ Cash-in-lieu of commodities
Signature of Administrator or Authorized Representative Date
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SPECIAL DIET STATEMENT FOR INFANTS
The infant named below is a participant in the Colorado Department of
Health Child & Adult Care Food Program (CACFP) . His or her day care
provider is required to serve the infant according to the minimum
requirements of the CACFP (see reverse) . Substitutions may be made if
individual participating children are unable, because of medical or other
special dietary needs, to consume such foods. Such substitutions shall be
authorized by a recognized medical authority, i.e. , a physician, a mid-
level caregiver such as a physician's assistant, nurse practitioner, or
child health associate, or a registered dietitian. The recognized medical
authority should specify in writing the food(s) to be omitted from the
infant' s diet and the food(s) which may be substituted for the meal
component. If the substitution is for an extended length of time, medical
orders for such substitution should be revised on a semiannual basis.
Today' s Date Substitution Effective Through
Infant' s Name Age
Provider/Center' s Name
In order to allow the substitution of a food in the pattern, check the
appropriate statement below and include recommended alternate food(s) .
Non iron-fortified infant formula substituted for iron-fortified
infant formula for infants under 12 months. List recommended
alternative food(s) :
NOTE: Infants under one year do not require a special diet
statement if served soybean-based formula.
Iron-fortified infant cereal (IFIC) has been eliminated from
infant' s diet (ages 8 - 12 months) . List recommended alternative
food(s) :
Infant approved to be served (Circle one of the following) :
Whole Milk 2% Milk 1% Milk Skim Milk
Milk allergy. List special instructions, if any. List
recommended alternative food(s) :
Other. Give brief explanation. List recommended alternate food(s) :
Signature of Recognized Medical Authority
6/90 u
''1.. 1. 6
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COLORADO DEPARTMENT OF HEALTH
CHILD AND ADULT CARE FOOD PROGRAM
DONATED FOODS (COMMODITIES) ADDENDUM
Center or Sponsor Name: Family Educational Networm 84 Agreement X84 6000814
The USDA Donated Foods (Commodities) Program in Colorado is administered by the Colorado Department of
Social Services.The role of the Colorado Department of Health Child and Adult Care Food Program is limited to the
following duties:
1. Explain the choice of donated foods to centers or sponsors. (There are two choices).
2. Report the choice of donated foods by centers or sponsors to the Colorado Department of Social
Services.
3. Reimburse centers or sponsor according to choice of donated foods.
4. Assist in. monitoring the proper distribution, storage. and use of donated foods during site reviews or
visits.
The two choices for donated foods are: (1) regular donated commodities. or(2)cash-in-lieu of commodities. Regard-
less of choice.you will receive monetary reimbursement for allowable meals served to children. Rates of reimburse-
ment vary according to meal type,income category,and choice of donated foods.Please refer to your current rates of
reimbursement.
Choosing regular donated commodities entitles you to receive various canned,frozen, and dry foods depending on
what USDA purchases for the year in addition to the regular meal reimbursement.
Choosing cash-in-lieu of commodities entitles you to receive 1 =. cents more reimbursement for every lunch or sup-
per that you claim.
Every spring a survey is mailed to all Child and Adult Care Food Procram centers or sponsors.At this time,you make
the choice of donated foods for the next commodity year,whicn begins July 1.This choice cannot be changed until
the next spring survey. PLEASE NOTE: If you enter the Child & Adult Care Food Program otner than curing the
spring survey, you can only receive casn-m-lieu of commodities.
The Colorado Department of Social Services will send you a aonated foods packet including an order form after we,
the Colorado Department of Health Child&Adult Care Food Program,inform them of your participation and choice of
donated foods.
By signing this addendum,you are indicating that you understand its contents. If you completed the spring survey
your choice is indicated below. If you are a new Program participant, you must indicate the cash-in-lieu
choice.
The center or sponor will receive:
L� Regular donated commodities
❑ Cash-in-lieu of commodities
-e'-C-F-' "AK.
Signature of Administrator or Authorized Representative Date
5/90
STATE. OF COLORADO
DEPARTMENT OF SOCIAL SERVICES of Coto
91
Den Sherman do 80203
0 �,� ��
Denver. Colorado 802 03-1 713 r p
Phone (303) 866-5700 "JNp
/�
*1876
Roy Romer
Governor
Irene M_ Iharra
Executive Director
May 9 , 1990
Ms . Terri Keller
Weld County Head Start Migrant Program
520 13th Ave.
Greeley, Co. 80631
Dear Ms . Keller:
Subject: License No. 58'236
This letter is in response to your recent inquiry regarding the
status of the license for Weld County Head Start Migrant Program.
Rule 7 . 701. 32-B of the Licensing Rules of General applicability
states that:
If the completed and signed application for renewal of the
license and appropriate fee are received by the Department
before expiration of the license, the application is timely
and the license continues valid until licensing action is
taken by the Department.
The child care license was to expire on August 11 , 1988 .
However, a renewal application was received on June 7 , 1933 so
the license continues valid until licensing action can be taken,
An inspection visit will be made in the future. The license will
be renewed only after the licensing evaluation can be conducted
and any areas found in violation of licensing regulations can be
corrected.
Sincerely,
® r=
Sharon Chavez
Licensing Specialist
Office of Child Care Services
STATE OF COLORADO
DEPARTMENT OF SOCIAL SERVICES oe COQ
1575 Sherman Street `� �'$
Denver �
, Colorado 80203-1713 7 O
Phone (303) 866-5700 +ti, `rte r r)
\'/8�
Roo Romer
Governor
Irene M. Ibarra
Executive Director
May 9 , 1990
Ms . Terri Keller
weld County Migrant Head Start Program South
340 Maple
Fredrick, Co. 80530
Dear Ms . Keller:
Subject: License No. 66816
This letter is in response to your recent inquiry regarding the
status of the license for Weld County Migrant Head Start Program
South.
Rule 7 . 701 . 32-B of the Licensing Rules of General applicability
states that:
If the completed and signed application for renewal of the
license and appropriate fee are received by the Department
before expiration of the license, the application is timely
and the license continues valid until licensing action is
taken by the Department.
The child care license was to expire on May 23 , 1989 . However , a
renewal application was received on March 21 , 1989 so the license
continues valid until licensing action can be taken . An
inspection visit will be made in the future. The license will be
renewed only after the licensing evaluation can be conducted and
any areas found in violation of licensing regulations can be
corrected.
Sincerely, \
CL\ems
Sharon Chavez
Licensing Specialist
Office of Child Care Services
STATE Or COLORADO
DEPARTMENT OF SOCIAL SERVICES ;of
1575 Sherman Street Fe/ ae
Denver, Coiorado 80203-1714 O
Phone (1031 866-5700
'kt)
l 'I'
Rov Romer
Governor
Irene St Ibarra
Executive Director
May 22 , 1991
Ms. Tere Keller
520 13 AVE
GREELEY, CO 80631
RE: Application Fee Receipt for License Number 77740
Facility Name: WERNER ELEM SCH MIGRANT HEAD START
Dear Ms. Keller:
Thank you for submitting your original application for a child care
license. This letter serves as your official receipt for payment
of a license fee in the amount of $50. 00 and verification that your
application was received by the Office of Child Care Services on
5/13/1991.
If your application was complete it has been forwarded to the
licensing specialist for processing. If your application was not
complete you will receive notice from this department indicating
information and materials needed to complete the application.
Should you receive a notice requesting additional information,
please send the requested information or materials by the date
indicated to avoid a further delay in the processing of your
application.
We appreciate your efforts to provide quality child care for
Colorado ' s families. If you have questions, please call our
offices at (303) 866-5958 .
Sincerely,
��
A H '
y
Grace Hardy
`Director
Office of Child Care Services
cc: Larimer DSS
Ylw ;c.'•Th ..
STATE Or COLORADO
DEPARTMENT OF SOCIAL SERVICES of-Co1O
1575 Sherman Street Pr Pt
Denver, Coiorado 80203-1714 �. ��
Phone (303) 866-5700 '
;ti l u� �
� /876/8]6
Rov Romer
Governor
Irene M- Iharra
Executive Director
May 22 , 1991
Ms. Tere Keller
520 13 AVE
GREELEY, CO 80631
RE: Application Fee Receipt for License Number 77738
Facility Name: ST AUGUSTINES MIGRANT HEAD START
Dear Ms. Keller:
Thank you for submitting your original application for a child care
license. This letter serves as your official receipt for payment
of a license fee in the amount of $50 . 00 and verification that your
application was received by the Office of Child Care Services on
5/13/1991.
If your application was complete it has been forwarded to the
licensing specialist for processing. If your application was not
complete you will receive notice from this department indicating
information and materials needed to complete the application.
Should you receive a notice requesting additional information,
please send the requested information or materials by the date
indicated to avoid a further delay in the processing of your
application.
We appreciate your efforts to provide quality child care for
Colorado ' s families. If you have questions, please call our
offices at (303) 866-5958 .
Sincerely, _
A id,
� ;
Grace Hardy
Director _
Office of Child Care Services
cc: Adams DSS
€0.4 •
PURCHASE OF SERVICES
THIS AGREEMENT, made and entered into this day of ,
1991, by and between the County of Weld, State o a-forado, by and
through the Board of County Commissioners of Weld County, on behalf of
the Weld County Division of Human Resources ' Family Educational Network
of Weld County's Head Start Program, hereinafter referred to as "FENWC,"
and the Greeley/Evans School District 6, hereinafter referred to as
"School District."
WITNESSETH
That for and in consideration of the covenants herein agreed to be
kept and performed, the School District hereby agrees to provide to
FENWC the following described services based upon the following terms
and conditions:
1. The School District will provide breakfasts ana milk for
approximately two hundred ana five (205) children and seventy-five
(75) adults at a cost of seventy-five cents ($.75) per meal .
2. The School District will provide lunches and milk for approximately
two hunared and five (205) FENWC children and seventy-five (75)
adults at a cost of one dollar and forty-five cents ($1.45) per
meal .
3. The School District will provide snacks and juice for approximately
two hundred and five (205) children and seventy-five (75) adults at
a cast of forty-five cents ($.45) per snack.
4. The School District will submit a bill for services to the Weld
County Division of Human Resources, P.O. Box 1805, Greeley,
Colorado, by the 10th of the month for services provided during the
preceding month. The School District agrees to provide information
on the cost of the quantity of lunches served to enable FENWC to
comply with USDA reimbursement requirements.
5. FENWC will apply directly to USDA for reimbursement for each
child's meal by type (full paid, free, or reduced) each month. The
School District will not receive USDA reimbursement for these
meals.
FENWC agrees to pay the School Distract for all meals served to
Head Start children and staff. Such reimbursement will be made
within three (3) weeks of the receipt of a statement of such
charges from the School District. The rate will be as described in
paragraphs 1 , 2, ana 3 above.
6. The School District agrees to provide meals in accordance with the
regulations of the United States Department of Agriculture's Child
Care Food Program as shown in Attachment A hereto, which is hereby
incorporated into this agreement.
7. The Schoc Jistrict will maintain the fol . .,ing records for FENWC:
a. Menu/Production Records , including number of meals prepared,
menu, portion sizes of menu items and amounts of food used to
prepare menu items. This is a requirement at the preparation
kitchen for all meals served.
b. Food and milk invoices. (Sent in weekly to the Food Services
office).
The records will be made readily available to FENWC for audit and
review purposes. The School District will maintain the records
within the record retention guidelines mandated by U.S.D.A.
8. FENWC will maintain a daily record of the number of meals served
by type.
9. No portion of this Agreement shall be deemed to constitute a waiver
of any immunities the parties or their officers or employees may
possess, nor shall any portion of this Agreement be deemed to have
created a duty of care with respect to any persons not a party to
this Agreement.
10. No portion of this Agreement shall be deemed to create an
obligation on the part of the County of Weld, State of Colorado, or
School District to expend funds not otherwise appropriated in each
succeeding year.
11. If any section, subsection, paragraph, sentence, clause, or phrase
of this Agreement is for any reason held or decided to be unconsti-
tutional , such decision shall not affect the validity of the
remaining portions. The parties hereto declare that they would
have entered into this Agreement and each and every section,
subsection, paragraph, sentence, clause, and phrase thereof
irrespective of the fact that any one or more sections,
subsections, paragraphs , sentences, clauses , or phrases might be
declared to be unconstitutional or invalid.
12. The term of this Agreement shall be from June 10, 1991 through
September 27, 1991.
13. This agreement may be amended at any time with the written mutual
consent of both parties.
14. The School District and FENWC mutually agree to accept that this
agreement may be terminated by either party upon a thirty (30) day
written notice being provided to the other party. However, this
agreement will be terminated immediately if Head Start funding is
stopped.
15. School District warrants that foods delivered to and/or picked up
by FENWC, as mutually agreed, shall be, at the point of transfer,
free of contamination and at safe and appropriate temperatures in
accordance with Department of Health and Sanitation standards.
FENWC agrees to relieve School District from all liability and/or
responsibility for any injury, damage, or loss to any person(s)
arising from consumption of foods which have been turned over to
FENWC for further transport and handling, and to indemnify and hold
the School District harmless from such consequences.
IN WITNESS WHEREOF, the parties hereunto have caused this agreement
to be duly executed as of the day, month and year first hereinabove set
forth.
WELD COUNTY BOARD OF COMMISSIONERS GREELEY/EVANS SCHOOL DISTRICT 6
Gordon E. Lacy, Chairman J. Timothy Waters, Ed.D.
Superintendent
WELD COUNTY DIVISION OF HUMAN ATTEST:
RESOURCES
WELD COUNTY CLERK TO THE BOARD
By:
Walter J. Speckman Deputy Clerk to the Board
Executive Director
Attachment A
Lunch or Supper
The minimum amounts of food components to be served as lunch or supper
as set forth are as follows:
Food Components Age 3 up to 6
MILK
Milk, fluid 3/4 cup1
VEGETABLES AND FRUITS
Vegetable(s) and/or fruits(s)2 1/2 cup total
BREAD AND BREAD ALTERNATIVES3
Bread 1/2 slice
or
Cornbread, biscuits , rolls , muffins , etc.4 1/2 serving
or
Cooked pasta or noodle products 1/4 cup
Cooked cereal grains or an equivalent quantity of
any combination of bread/bread alternative 1/4 cup
MEAT AND MEAT ALTERNATIVES
Lean meat/poultry or fishy 1 1/2 oz.
or
Cheese 1 1/2 oz.
or
Eggs 1 egg
or
Cooked dry beans or peas 3/8 cup
or
Peanut butter or an equivalent of any combination of
meat/meat alternative 3 tbsp.
1 For purposes of the requirements outlined in this subsection, a cup
means a standard measuring cup.
2 Serve two or more kinds of vegetable(s) and/or fruit(s) .
Full-strength vegetable or fruit juice may be counted to meet not
more than one-half of this requirement.
3 Bread, pasta or noodle products , and cereal grains shall be whole
grain enriched; cornbread, biscuits, rolls, muffins, etc. , shall be
made with whole grain or enriched meal or flour.
4 Serving sizes and equivalents to be published in guidance materials
by FNS.
5 Edible portion as served.
C41 :,
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