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Home My WebLink About931018.tiff RESOLUTION RE: APPROVE PURCHASE OF SERVICE AGREEMENT FOR CHILD AND ADULT CARE FOOD PROGRAM WITH THE COLORADO DEPARTMENT OF HEALTH 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 Purchase of Service Agreement for Child and Adult Care Food Program between Colorado Department of Health and Family Educational Network of Weld County (FENWC) , commencing October 1, 1993, and ending September 30, 1994, with further terms and conditions being as stated in said agreement, and WHEREAS, after review, the Board deems it advisable to approve said agreement, 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 Purchase of Service Agreement for Child and Adult Care Food Program between Colorado Department of Health and FENWC be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is, authorized to sign said agreement. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 29th day of September, A.D. , 1993. BOARD OF COUNTY COMMISSIONERS ATTEST: �L�2lx 7 WE COUNTY, COLORADO Weld County Clerk to the Board {r,,S>4-ne.a-.Vd1.4626r Constance L. H!arb/eeert,/1 Chairman BY: 6/)Yfr a/6/64 Deputy Cle k o the oard W. H Webster, Pro- em APPROVED AS TO FORM: ` �� X eorge Baxter unty Attorney . Hall 4 - Barbara �,J. Kirkm yer 931018 HI20O 57 (G ,' //X', STi','. CDH-CACFP CERTIFICATE AND STATEMENT OF AUTHORITY CHECK CORRECT BOX: x NONPROFIT ORGANIZATION ❑CHURCH ❑FOR PROFIT ORGANIZATION! I,(We),the undersigned,state that the child care center(s)listed on Schedule A of the Agreement(CACFP 300)is an integral part of and therefore under the direct control of and supervision of the governing body of the Weld County Division of Human Resources ' Family Educational Network of (Name of the Organization,Business or Church) Weld County whose address is 1551 N. 17th Avenue , P . O. Rnx 1on Greeley, CO 80632 (Street or Route) (City) (Zip Code) 303 ) 353— 3800 (Telephone Number) and that all funds relating to the Child and Adult Care Food Program (CACFP)will be subject to the control of the duly constituted governing body of the above-named organization,business, or church and that all funds received for the operation of the CACFP will be used exclusively for the purpose for which they were received.The individual(s) whose name and signature appears below is authorized to sign the Agreement and all other official documents in connection with the CACFP. AUTHORIZED REPRESENTATIVE(S) 17Tref...e. anry- Signature Tere Keller-Amava Janet Luna-F1at,gher Print Name Print Name Director of FENWC Site Manager of FENWC Title Title is the duly designated Authorized Representative(s)for the Center/Sponsor listed above.It is to your benefit to have two people designated as Authorized Representatives. The Authorized Representative(s) is fully-empowered to enter into any agreement with the Colorado Department of Health CACFP and may act for the above-mentioned center or sponsor in preparing and signing documents and reports pertaining to the management of the CACFP. When there is a change of Authorized Representative R shall be the responsibility of the center or sponsor to request from this office Colorado Department of Health CACFP forms to register the change. The signature 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. MAILING ADDRESS: If you would like your reimbursement check sent to an address different from the above, please write it here: Street Address City State Zip Code Business Phone THIS BOX MUST BE SIGNED l(we understand that the information on this form is being given in connection with the receipt of Federal kinds an at all of the provision of a Agreement(CACFP 300) apply. E ' Constance Harbert Chairperson ignature of Chair of the Board of irectors, Print Name pOO{tfival Ti or Pastor,or Executive Director, 7/9/619 93 or Owner /02447843 Da (4/92) OVER 9'71 M 65103-05-1 A. COMMODITIES FAMILY EDUC NETWORK OF WELD If you completed the Spring Survey,your center chose the following: ***CASH-IN-LIEU OF COMMODITIES*** If you began participation on the CACFP after the Spring Survey,your center will receive cash-in-lieu of commodities. B. FOR PROFIT TITLE XX CENTER OR SPONSOR ONLY We certify that a least 25 percent of the children enrolled or 25 percent of the license capacity in one or more of our centers received Title XX benefits in the calendar month prior to submitting this application to the Colorado Department of Health, Child &Adult Care Food Program (CDH-CACFP). We further certify that: ❑ We have submitted a copy of each of our contracts with the Title XX administering agency (Department of Social Services)to the CDH-CACFP. ❑ We have submitted a roster of ail enrolled participants,with Title XX beneficiaries identified,from the month previous to this application/renewal. ❑ All centers listed on the Agreement CACFP 300 share the same legal identity as the sponsor. Only centers that meet the"25 percent"requirement are listed. ❑ We will not submit a Claim for Reimbursement for a center(s)which does not meet the"25 percent" requirement. C. FOURTH MEAL 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. ❑ O,a fourth meal will not be claimed.(Do not complete the rest of Part C.) / YES,a fourth meal will be claimed. i�9 4 ` If yes,Type of meal S Time of Meal ca- 1 0 \--"lc.--k0 rn Effective Date -\--"lc.--ka 1 w,, a re ❑ We keep time-in/time-out records. OR %The end of the first meal and the be innin of the 4th meal are 8 hours apart. When does first meal END? y)'-D C AM When does 4th meal BEGIN?C C C PM D. NONDISCRIMINATION POLICY STATEMENT (Nonpricing Centers) We assure the Colorado Department of Health,Child and Adult Care Food Program that all enrolled participants in the Child&Adult Care Food Program at the center(s)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. qfa�/ Sign ure of Administrator or A orized Representative Date Administrator Signature of the CDH-CACFP Title Date 97n ":1019rerFa 1.11Q1) A 'DIT QUESTIONNAIR' Child&Adult Care Food Program (CACFP) Organizations receiving federal funds are required to be audited. The information requested on this form will help us satisfy those requirements. It may be helpful to have someone in your accounting office prepare this questionnaire. Center/Sponsoring Organization:Family Educational Network Agreement Number: nR-Hsinl of Weld County Address: 1551 North 17th Avenue P . O. Box 1805 Greeley, Colorado 80632 1. Do you contract with an accounting firm to conduct an audit of your center/sponsoring organization? Yes No x 2. If your center/sponsor is part of another organization, does the organization have an organization-wide audit? Yes x No The term "organization-wide audit" means an audit of all funds received by an organization, including federal, state, local, and private funds. The audit must include a random sampling of all federal funds received by the organization, and it must be conducted by an independent auditor. 3. Is a review of the CACI•? included in that organization-wide audit? Yes x No 4. What is the legal name of the organization being audited? Weld County 5. What federal funds does your organization receive other than CACl/Y? (Examples: National School Lunch Program, Title XX) DHHS - Head Start & Migrant uAad Stjrt DOL - JTPA Funds & Joh cor.,; co $ AAA - Senior Programs $ USDA - fgpp_ Senior Nutrition $ CSBG 6. What is the total annual budget for the organization identified in Question #4? (include all federal, state, and "other" funds) $ 5 . 5 Million 7. When does your organization's fiscal year begin and end? January 1 through December 31 8. Does your organization have fiscal year end schedules (financial statements)? Yes x No 9. Does your organization have computerized records? Yes x No Quetionnairepreparedby: Marilyn Carlino Dale: 8/23/93 Title: Fiscal Officer PhoneNumber: ( 303) 353=3800 (Rev.7/92) S?ififl COLORADO DEPARTMENT HEALTH AGREEMENT NUMBER CHILD & ADULT CARE FOOD PROGRAM APPLICATION FOR 08-65103 SPONSOR OF CHILD CARE CENTERS ents, INSTRUCTIONS: Completogetherewith CACFP 3 1in duplicate. bmit original,(Application cortlnuation Child Careeets if needed, and Center), and attachments.dTypecornprint clearly. 1. NAME AND MAILING ADDRESS OF SPONSOR 6. IS THIS A PRIVATE ORGANIZATION?(Private means non-governmental) Weld County Division of Human Resources YES NO X Family Educational Network of Weld County Give name and title of Owner of For Profit Title XX Center OR Chair of the 15_51 North 17th Avenue Organization Governing Board OR Chair of the Church Governing Board: P . O . Box 1805 Weld County Board of County Greeley , Colorado 80632 Commissioners Constance L . Harbert , Chairperson TELEPHONE NO:( 303 ) 353-3800 TITLE COUNTY: 2. DO YOU PARTICIPATE IN THE HEAD START PROGRAM? 7. NUMBER OF CACFP-PARTICIPATING-CENTERS UNDER YOUR ADMINISTRATION YES Yr NO_ NONPROFIT CHILD CARE CENTERS OUTSIDE-SCHOOL-HOURS CENTERS 3. DO YOU NOW PARTICIPATE IN OR HAVE YOU PARTICIPATED IN FOR PROFIT TITLE XX CENTERS FEDERALLY-FUNDED PROGRAMS (including CACFP) IN THE PAST 3 12 HEAD START CENTERS YEARS? YES_ NO _La_ MIGRANT HEAD START CENTERS (If "yes,"give name of program(s)and dates of participation.) 8. TOTAL NUMBER OF CHILDREN ENROLLED AT CACFP-PARTICIPATING CENTERS UNDER YOUR ADMINISTRATION CACFP 1985 to present NONPROFIT CHILD CARE CENTERS 4. DO YOU PARTICIPATE IN THE COLORADO PRESCHOOL PROJECT? OUTSIDE-SCHOOL-HOURS CENTERS YES X NO 5. NAME AND TITLE OF ADMINISTRATOR FOR PROFIT TITLE XX CENTERS Walter J . Speckman , Executive Director HEAD START CENTERS 490 Name Title NAME AND TITLE OF CONTACT PERSON MIGRANT HEAD START 400 Tere Keller-Amaya , Director CENTERS Name Title 9. DO YOU REQUEST ADVANCE PAYMENTS? TELEPHONE NO:( 303 ) 353- 3800 YES NO X 10. LIST ANY MONTHS WHEN YOU WILL NOT CLAIM MEALS FOR REIMBURSEMENT. N/A DESCRIBE YOUR PROCEDURE FOR COLLECTING. MAINTAINING AND REVIEWING THE FOLLOWING RECORDS FROM EACH CENTER: 1. Income Eligibility Forms (IEF) 4. Production Records 2. Record of Meals Served (ROMS) 5. Food Receipts and Invoices 3. Menus Income eligibility forms are completed at the beginning of the school year . Teachers complete Record of Meals Serviced and turn into Family Services and the information is compiled for the Meal Claim Forms . At the beginning of the school year menus are formulated with the appropriate School Districts and approved by the Parent Policy Council . Production Records are done by the School District Cooks and reviewed by the Director . Invoices are approved by the Director and sent to the Fiscal Department for payment and recording purposes . Page 1 CACFP-302 (5/90) DECRIB cannot UR SYSTEM ST FOR DISBURSING RSIIlN clCACEP REIMBURSEMENT EyNTeOs YOUR.CENTERS WITHIN 5 DAYS OF RECEIPT FROM CDH-CACFP.(Reim- bursement e aintedAll centers are operated under the direction of the Head Start Program . Therefore , the CCFP reimbursement is made to the one program and does not need to be disbursed to the other facilities . All costs for each of the centers are paid under the one Head Start Budget . LS? YES X If ILLyes, please g eRcompany name address,and ameAof contact pO son and GEMENT CMPANY Fdelivery OR Aprocedures. NO_ Greeley/Evans School District 6 - Sue Roberts Garcia Weld School District RE- 3J - Shirley Foos , Hudson Weld School District RE-5J - Milliken Weld School District RE- 1 - Gilcrest Food is prepared at a central location , delivered tote individual school cafeteria ' s and delivered to the classroom . Proper storage and food transport containers are used . St. Vrain School District RE- 1J - Cynthia Gruele - Frederick Food is prepared at the High crhnnl trancpnrtnd to the rlaccrnnm , I icing prnfPr PlluipmPnt DESCRIBE YOUR SCHEDULE FOR TRAINING ADMINISTRATIVE AND FOOD SERVICE PERSONNEL ON CACFP REQUIREMENTS(Give dates of training session(s) and topics to be covered.) All staff involved in food service will be trained in October . When new information is made available , training is provided to all necessary staff , reviews are conducted monthly when all the documentation is collected for reporting purposes . DESCRIBE YOUR PROCEDURE FOR CONDUCTING PRE-APPROVAL VISITS TO NEW CENTERS. IF AVAILABLE.ATTACH A COPY OF YOUR PREAP- PROVAL EVALUATION FORM. The pre-approval evaluation form will be used at each site . PROVIDE A SCHEDULE FOR MONITORING FOOD SERVICE OPERATIONS AT YOUR CENTERS. Monitoring of food service operations is done in November 1993 , February 1994 , May of 1994 , June 1994 and August 1994 . If problems are discovered during a monitoring review,what corrective procedure will you follow? An action plan will be written and follow-up in thrity ( 30) days . Page 2 CACFP-3O2(5/90) + Inn �] S.^-1 Inn SPONSOR STAFFING PATTERN FOR CACFP(List all sponsor personnel who will be involved in administering the CACFP in the chart below.Complete chart as specified,recording duties of personnel listed in ADMINISTRATIVE DUTIES directly related to the CACFP.Administrative duties include managing finances and operation of CACFP.Attach additional sheets if necessary.) SALARY PER HOUR NUMBER OF INCLUDING DAYS PER NUMBER OF FRINGE YEAR EACH SOURCE OF NUMBER OF HOURS PER DAY BENEFITS EMPLOYEE FUNDS FOR ANNUAL POSITION SPECIFIC CACFP PERSONNEL EACH EMPLOYEE (Indicate volunteers WILL SPEND SALARY CACFP-FUNDED DUTIES IN THIS WILL SPEND ON and unpaid work ON CACFP (CACFP or) SALARY POSITION CACFP DUTIES with"'"") DUTIES other) ONLY A B C D E F G (DXEXF) ADMINISTRATOR Reimbursements 1 varies $15 . 00 ! 12' State • for equivalent) H H S ASSISTANT Coordinates - ADMINISTRATOR WI,tIc h001s 1 varies $11 . 00 83 for epuivalentl �^ CLERICAL Typing (or equivalent) Correspondence 2 varies $ 7 . 00 25 COOK OTHER (specify) ANNUAL CACFP ADMINISTRATIVE BUDGET TOTAL CACFP-FUNDED LABOR 0 (ENTER CACFP PORTION ONLY) CACFP-FUNDED LABOR (Enter total from above) S OFFICE SUPPLIES(Including reproduction costs) POSTAGE TRANSPORTATION FOR FACILITY MONITORING(include mileage multiplied by 205) TELEPHONE OFFICE RENTAL/MORTGAGE PAYMENT AND MAINTENANCE UTILITIES FOR OFFICE AREA , OTHER(Specify) TOTAL CACFP ADMINISTRATIVE BUDGET S 0 ANNUAL CACFP BUDGET FOR FOOD SERVICE OPERATIONS AT FACILITIES UNDER YOUR ADMINISTRATION (ENTER CACFP PORTION ONLY) FOOD PURCHASES S FOOD SERVICE LABOR(Salaries of staff preparing or serving meals) 141, qQ,Q 0 0 _ FOOD SERVICE CONTRACTOR FEE NONFOOD SUPPLIES(Napkins straws,dishwashing detergent,etc.) MAINTENANCE FOR FOOD PREPARATION,STORAGE AND SERVICE AREAS RENT/MORTGAGE PAYMENT FOR FOOD PREPARATION,STORAGE AND SERVICE AREAS UTILITIES OTHER(Specify) TOTAL FOOD SERVICE OPERATING BUDGET $: 140 , 000 . 00 LIST SOURCES OF CASH INCOME SPECIFICALLY FOR THE FOOD SERVICE OTHER THAN CACFP REIMBURSEMENT. Head Start Grant , Migrant Head Start Grant & State Preschool Funds • I certify that the information on this application and the attached form CACFP-301 is true to the best of my knowledge;that I will accept final administrative and financial responsibility for total Child and Adult Care Food Program operations at all centers under my sponsorship;and that reimbursement will be claimed only for meals served to enrolled participants:that the CACFP will be available to all eligible participants without regard to race,color.sex national origin,age or handicap at the approved food service facilities and that these facilities have the capability for the meal service planned for the number of participants anticipated to be served or meals are provided bya food service management company in compliance with CACFP regulations.I understand that this informa- tion is being given in connection with the receipt of Federal funds and that deliberate misrepresentation may subject me to prosecution under applicable State and Fe era,cumin i statutes. 1/O y/9-3 ��(? SIGNATURE OF ADM( STRATOR OR AUTHORIZED REPRESENTATIVE ryD T/'E� i 01_ 7 Page 3 CACFP 302 IS/901 STATE OF COLORADO COLORADO DEPARTMENT OF HEALTH �4.0c cot°R Dedicated to protecting and improving the health and ew=�,NE la environment of the people of Colorado 4300 Cherry Creek Dr.S. Laboratory Building _.W.+ Denver,Colorado 80222-1530 4210 E. 11th Avenue *1676 Phone:(303)692-2000 Denver,Colorado 80220-3716 (303)691-4700 Roy Romer Governor Patricia A.Nolan,MD,MPH Executive Director August 1993 Dear Child and Adult Care Food Program Authorized Representative: Enclosed are your renewal materials for the Colorado Department of Health Child and Adult Care Food Program (CDH-CACFP) for Fiscal Year 1994(October 1, 1993 through September 30, 1994). Please complete the following forms and enclose other needed information as listed below. Return to our office by Wednesday, September 8,1993 in the envelope provided. NON-PROFIT CENTERS: RETURN: ScheduleA 1 copy I VI Center Application(on NCR paper) 1 copy for each site I t..< (white only) Certificate and Statement of Authority/Center 1 copy i rH Information Form-(Yellow) _Did you sign the form? _Did you complete front&back of form? INFANT MENUS: Return menus for two weeks for each meal claimed, L--Pet for each age group,if you claim infants on the CACFP. 0-3 months 3-7 months _ 8 months up to the first birthday CHILD'S MENU: Return menus for two weeks for each meal claimed. Breakfast Lunch Supper Food Service Contract,if applicable W Is your contract current? Audit Questionnaire 1 copy Ca- Sponsor Application,if you have more than one center. 1 copy Vol^ FOR-PROFIT CENTERS,please submit the additional forms: Copy of current Department of Social Services contracts for care of Title XX children. _ Are contracts current? Are all pages of each contract enclosed? Roster of all children enrolled in September 1993. Designate those children for whom Title XX payments were received. ;g�._9tfl Last year your center completed a two-year CACFP 300 Agreement which allowed you to participate through September 30,1914. To update files,renewing centers must fill out a Schedule Athis year rather than the entire CACFP-300..Your renewal,as always,isdependentupon whether the federalgovernmentappropriatesfundsfor the CACFP. _If you are a nonpri ring center,you axe no longerrequired to submitthe Public Service Announcement Press Release. Instead,the CDH-CACFP will sendthis release for you to your local news media announcing your intent to sponsor the CACFP inyour center(s).This will fulfill your Civil Rights obligation to advertise the availability of the CACFP to all members of your community. Again, ALL APPLICATION MATERIALS MUST BE COMPLETED AND RETURNED TO US BY WEDNESDAY,SEPTEMBER 8,1993 to the address listed below. Original signatures of an official having authority to enter into contracts on behalf of your organization are needed on your appli don tedS. You may want to consider returning all items by Certified Mail. Child&Adult Care Food Program Colorado Department of Health FCHSD-CAC-A4 4300 Cherry Creek Drive South Denver,CO 80222-1530 If you choose notto participate,we would appreciate your letting us know. If you have any questions,call our office at(303) 692-2330. Sincerely, 4' Kathryn A.Brunner,Administrator Child&Adult Care Food Program Enclosures (CDH-CACFP 7193) 1 7.1 Or-4 SCHEDULE A (CDH-CACFP Fiscal Year 1994' Does your organization have more than one licensed center? YES X NO Fill in the name, address and other information of your centers participating in the Child & Adult Care Food Program. (Attach additional sheets if necessary.) NAME&ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER C-Child Can H•Hood Stint CAPACITY 0-Wade LICENSE WRITTEN LICENSE il.Cgha pm rom had Hours NUMBER ON EXPIRATION X X X X LICENSE DATE BREMU:AST SNACK LUNCH PM SNACK SUPPER Billie Martinez A 341 14th Avenue 8783 s$5= `* 2S2'OO 5. 00! Greeley, CO 80631 .F ., NUMBER OF CHILDREN 30 60 30 30 Centennial 1400 37th Street $ 183.1 Evans , CO 80620 NUMBER OF CHILDREN 30 60 30 30 TIMES OF MEALS Dos Rios H 2201 34th Street 81829 Evans , CO 80620 ., NUMBER OF CHILDREN 30 60 30 30 TIMES!OF MEALS 81 &30 ' East Memorial H 614 East 20th Street 10/23 . Greeley, CO 80631 94 NUMBER OF CHILDREN 30 60 30 30 TIMES OF MEALS Frederick H 66816 340 Maple Frederick , CO 80530 NUMBER OF CHILDREN 54 54 54 54 This schedule is part of CACFP 300 signed Fiscal Year 1993. a"'I 01? Due to an error, item #1 on page one is incomplete. It should read as follows: 1. It will comply with Title VI of the Civil Rights Act of 1964 (P.L. 88- 352) and all requirements imposed by the Regulations of the Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR parts 42 & 50), and FNS directives or regulations issued pursuant to that Act and the Regulations, to the effect that, no person in the United States shall, on the grounds of age, sex, handicap, color, race, or national origin, be excluded from participation in, or be denied the benefits of, or be otherwise subject to discrimination under any program or activity for which the applicant received Federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement. THIS ASSURANCE IS given in consideration of and for the purpose of obtaining any and all Federal financial assistance, grants and loans of Federal funds, reimbursable expenditures, grant or donation of Federal property and interest in property, the detain of Federal personnel, the sale and lease of, and the permission to use, Federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements made with Federal financial assistance extended to the applicant by the Department. This includes any Federal agreement, arrangement, or other contract which as one of its purposes the provision of assistance such as food, food stamps, cash assistance for the purchase of food, and any other financial assistance extended in reliance on the representations and agreements made in this assurance. BY ACCEPTING THIS ASSURANCE, the center or sponsor agrees to compile data, maintain records and submit reports as required, to permit effective enforcement of Title VI and permit authorized CDH personnel during normal working hours to review such records, books and accounts as needed to ascertain compliance with Title VI. If there are any violations of this assurance, the Department of Health, Nutrition Services shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the center or sponsor, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from the State Agency. SCHEDULE A (CDH-CACFP Fiscal Year 1994 Does your organization have more than one licensed center? YES x NO Fill in the name, address and other information of your centers participating in the Child & Adult Care Food Program. (Attach additional sheets if necessary.) NAME &ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER c-Child Cars H"Head Stile CAPACITY x x x x Mk Outside LICENSE WRITTEN LICENSE N. g na School Hours R For qom NUMBER ON EXPIRATION LICENSE DATE BREAKFAST SNACK LUNCH PM SNACK SUPPER TIMES OF(i,EAlS Gilcrest H '' 1175 Birch 65080 Gilcrest , CO 80623 f •? NUMBER OF CHILDREN 30 60 60 0 gggaigiaMmg*„prMESA-:,;p.:.:- „ Hudson H 81828 300 Beech Hudson , CO 80642 NUMBER OF CHILDREN 30 60 30 30 TIMES'OFMFAIS Island Grove Village H 85077 119 14th Avenue Greeley, CO 80631 _ .. NUMBER OF CHILDREN 15 30 15 0 Jefferson H TIMES'OF MI'ALS 1315 4th Avenue 81831 30 10/23/91 Greeley, CO 80631 NUMBER OF CHILDREN 30 60 30 30 ................ . ... TIMES iOF MEALS Madison H 24th Ave. & 6th Street 81832 Greeley, CO 80631 NUMBER OF CHILDREN 30 60 30 30 This schedule is part of CACFP 300 signed Fiscal Year 1993. SC 1019 Due to an error, item #1 on page one is incomplete. It should read as follows: 1. It will comply with Title VI of the Civil Rights Act of 1964 (P.L. 88- 352) and all requirements imposed by the Regulations of the Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR parts 42 & 50), and FNS directives or regulations issued pursuant to that Act and the Regulations, to the effect that, no person in the United States shall, on the grounds of age, sex, handicap, color, race, or national origin, be excluded from participation in, or be denied the benefits of, or be otherwise subject to discrimination under any program or activity for which the applicant received Federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement. THIS ASSURANCE IS given in consideration of and for the purpose of obtaining any and all Federal financial assistance, grants and loans of Federal funds, reimbursable expenditures, grant or donation of Federal property and interest in property, the detain of Federal personnel, the sale and lease of, and the permission to use, Federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements made with Federal financial assistance extended to the applicant by the Department. This includes any Federal agreement, arrangement, or other contract which as one of its purposes the provision of assistance such as food, food stamps, cash assistance for the purchase of food, and any other financial assistance extended in reliance on the representations and agreements made in this assurance. BY ACCEPTING THIS ASSURANCE, the center or sponsor agrees to compile data, maintain records and submit reports as required, to permit effective enforcement of Title VI and permit authorized CDH personnel during normal working hours to review such records, books and accounts as needed to ascertain compliance with Title VI. If there are any violations of this assurance, the Department of Health, Nutrition Services shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the center or sponsor, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from the State Agency. SCHEDULE A (CDH-CACFP Fiscal Year 1994 Does your organization have more than one licensed center? YES x NO Fill in the name, address and other information of your centers participating in the Child & Adult Care Food Program. (Attach additional sheets if necessary.) NAME&ADDRESS TYPE OF LICENSE MEALS TO BE CLAIMED OF CENTER CENTER C-Child Cam H-Hnd Bled CAPACITY outims X X Hobos Hour, LICENSE WRITTEN LICENSE X !, ti9 hO. p.For prom NUMBER ON EXPIRATION UCENSE DATE BREAKFAST SNACK LUNCH PIA SNACK SUPPER NOWNW......................................... . TIMBc RF MEALS Nowa Milliken H &5074 300 Broad Street Milliken , CO 80543 NUMBER OF CHILDREN 35 60 30 TiMt�ii:CFMEALS•L f NUMBER OF CHILDREN 11MES OF MEALS Brighton (Migrant Only) H - ! Waiting Site to be determined in May 1994 (J NUMBER OF CHILDREN 50 50 50 501 ...................... . . ****NOTE : The times for MEAi,S the Migrant Programs are different from the times indicated on this contract. - - NUMBER OF CHILDREN TIMES OF MEALS NUMBER OF CHILDREN This schedule is part of CACFP 3OO signed Fiscal Year 1993. 9?I OV4 Due to an error, item #1 on page one is incomplete. It should read as follows: 1. It will comply with Title VI of the Civil Rights Act of 1964 (P.L. 88- 352) and all requirements imposed by the Regulations of the Department of Agriculture (7 CFR Part 15), Department of Justice (28 CFR parts 42 & 50), and FNS directives or regulations issued pursuant to that Act and the Regulations, to the effect that, no person in the United States shall, on the grounds of age, sex, handicap, color, race, or national origin, be excluded from participation in, or be denied the benefits of, or be otherwise subject to discrimination under any program or activity for which the applicant received Federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement. THIS ASSURANCE IS given in consideration of and for the purpose of obtaining any and all Federal financial assistance, grants and loans of Federal funds, reimbursable expenditures, grant or donation of Federal property and interest in property. the detain of Federal personnel, the sale and lease of, and the permission to use, Federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements made with Federal financial assistance extended to the applicant by the Department. This includes any Federal agreement, arrangement, or other contract which as one of its purposes the provision of assistance such as food, food stamps, cash assistance for the purchase of food, and any other financial assistance extended in reliance on the representations and agreements made in this assurance. BY ACCEPTING THIS ASSURANCE, the center or sponsor agrees to compile data, maintain records and submit reports as required, to permit effective enforcement of Title VI and permit authorized CDH personnel during normal working hours to review such records, books and accounts as needed to ascertain compliance with Title VI. If there are any violations of this assurance, the Department of Health, Nutrition Services shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the center or sponsor, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from the State Agency. COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YES NO St. ant On ustine A ' s (Migrant ) CHILDREN/INFANTS ON A REGULAR BASIS? X 4 g Y WILL YOU CLAIM THESE CHILDREN/INFANTS 675 Edgbert ONTHECACFP? X — Brighton , CO 80601 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YESX NO TELEPHONE NO.: ( ?O ) F 5 9-7 l R 7 She care means that dildran are coming and going at all times of the day so that me COUNTY: W a 1 rl total number of children attending the center on a daily basis may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. 8. HOURS OF OPERATION Dorothy Perez FROM 7 : 00 am TO 5 . 00 pm 3._HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING ->.-.MIGRANT HEAD START PROGRAM 4 DAYS PER WEEK 5 WEEKS PER YEAR 12 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 4 11. ANNUAL DATES OF OPERATION HOW MANY ARE AM? 4 HOW MANY ARE PM? HOW MANY ARE FULL DAY?_...4,— STARTING 5/3 1 ENDING l (1/1 NUMBER OF CHILDREN IN EACH CLASSROOM will vary is your Head Start site licensed as a child rare center by the Colorado Department 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services dining tines when Head Stan is not in session? AND SNACKS FOR REIMBURSEMENT YES X NO__ (Include dates of closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN N/A FROM 0 TO 5 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? x I CHANGED? I WILL YOU CLAIM THESE INFANTS ON YES NO X THE CACFP? X - 14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? ,,I PREPARATION AT FEEDING LOCATION YES x NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR -X sNDMER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? YES X NO UNDER CONTRACT WITH FOOD SERVICE CATERER(SUBMIT COPY OF CONTRACT) 17 FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF I?EARS SPECIFIC CACFP STAFF•N I N Tr,s NAME OF POSITION NAME OF PERSON FOOD SERVICE DUTIES HIS POSITION(POSITION' As per District Contract ' servinq children food l0 ' 1T-try Teacher/Teacher Assistant lnnatc.l np ritc - Lunch Aide lnnatAH serving children food 1 I' xrn r co cite 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) __PRICING(Please contact our office for further Instructions at 692-23Yi) �t_NONPRICING In a pricing program.centers establish a charge generate from tuition for meals in order to make up the dinerence between the reimbursement provided by the CACFP and the actual cost of serving the meats.In a n orpnang 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. 19.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 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBLIC SCHOOL DATA. HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAL/ETHNICBREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL American Indian or Alaskan Native 5% Asian or Pacific Islander Back(not of Hispanic ongin) Hispanic q n 9- white (not of Hispanic origin) 'Visual identification may be used by carters a sponsors to determine the child's racial/Ohm category.A child may be ncluded in the group to Mach he or site appears to belorg. identifies with.or a regarded in the community as belonging_Parents/Guamara may be asked to identity the racatiethne group of their own child alter it has been explamned.and tnev as well as we understand that the collection of this inforrratlon S strictly for etatiencal reporting requirements and has no cited on the determination of their eligibility to receive nenel its I under the Program.As new children are enrolled,you will need to determine their racist/ethnic background and sap this Intcemaden In a confidential place. CACFP-301 (4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 9„T1 9in COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YES NO Ft. Morgan (Migrant Only) CHILDREN/INFANTS ON A REGULAR BASIS? _x___ - 9 q y WILL YOU CLAIM THESE CHILDREN/INFANTS X Site To Be Determined in May 1994 ON THE CACFP? — TELEPHONE NO.: ( ) 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YES x NO Shill care means that Miioren are coming and going at all limes of the day so that the COUNTY: total number of children aends the center on a daily basis may exceed the license Double Sessions 2. NAME AND TITLE OF CONTACT PERSON AT CENTER pct, 8. HOURS OF OPERATION — Dora Lopez FROM 7 . 00 am TO 9 . 00 pm .3. -HEAD START PROGRAM 9. NUMBER OF OPERATING 10. NUMBER OF OPERATING ?- -.MIGRANT HEAD START PROGRAM DAYS PER WEEK WEEKS PER YEAR HOW MANY HEAD START 3 CLASSROOMS DO YOU HAVE?-3-- 11. ANNUAL DATES OF OPERATION HOW MANY ARE AM? HOW MANY ARE FULL DAY? Z STARTING 5/3 1 ENDING 8/31 NUMBER OF CHILDREN IN EACH CLASSROOM Atli-v a r y Is your Head Stan site licensed as a child care center by the Colorado Department 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during times when Head Start is not in session? AND SNACKS FOR REIMBURSEMENT YESX NO (Include dates of closing and reopening) l 4.AGE RANGE OF ENROLLED CHILDREN N/A FROM O TO 5 5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? _3L CHANGED? WILL YOU CLAIM THESE INFANTS ON YES NO X THE CACFP? 14. METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? PREPARATION AT FEEDING LOCATION YES X NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALSSERVED FORMS BEING KEPT FOR X UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMIT COPY oFCONTRACT) YES x NO UNDER CONTRACTRWITH FOOD SERVICE CATERER 17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS I NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN IN THIS FOOD SERVICE DUTIES THIS POSITION POSITION) As required per District Contract I I I ! Teacher/Teacher Assistant located on site serving rhildrpn fnnR r woryi I 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) _PRICING(Please contact our office for further instructions at 692-233c)) X NONPRICING In a prong program.centers establish a charge sarara+e from tuknn 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 norpnang program.families pay a general tuition large that covers ae areas of child care services provided by the center,including meals.There is no identifiable separate charge for meals served to any cNkinan in care • 19.All participating centers or sponsors am eligible to receive advance payments.Advan ces are requested monthly by filling out an advance form.The j amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimoursement. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS 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 1 Q% Asian or Padllc Islander _ - Black(not of Hispanic origin) Hispanic 9 O%% • White (not of Hispanic origin) 'Vista identification may be used by carters or sponsors to Siemens the child's ra®Vethnic category.A Cited may be included tithe group to which he or she appears to belong. identifies with,or is regarded in the community as belonging.ParentaGuardans may be asked to identity the racial/ethnic group of thew own chid Merit has been explained.and they as well as we unnerstand that the collection of this information is strictly for statistical reporting requirements and has no effect on the determination of their elgbittry to receive benefits under the Program As new children are enrolled,you will rind to determine their raaalletlnk bsarground and keep this Information Ina co adentlel place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6.DO YOU CARE CHILDREN/INFANTS OE FORSPECIAL REGULAR BASIS? YES NC Madison WILL YOU CLAIM THESE CHILDREN/INFANTS 24th & 6th Street ON THE CACFP? X Greeley , CO 80631 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES x NO TELEPHONE NO.: ( 303 ) 35 3—2796 Shift care means that cildren are coming and going at all times of the day so Ii COUNTY: WP 1 ri total number of children attending the center on a daily basis may exceed the Jr capacity. Double Sessions 2. NAME AND TITLE OF CONTACT PERSON AT CENTER B.HOURS OF OPERATION Larry Padgett FROM 7 : 00 am TO 5 : 00 pm 3. _HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING _-MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR 5 0 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 2 HOW MANY ARE AM?_.2.-HOW MANY ARE PM? 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING 10/1 ENDING 9/31 NUMBER OF CHILDREN IN EACH CLASSROOM___L5___ Is your Head Start site licensed as a child care center by the Colorado Department 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEF of Social Services during tines when Head Stan is not in session? AND SNACKS FOR REIMBURSEMENT YES X NO_ (Include dates of dosing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN FROM 0 TO 5 14/7), 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? -1L CHANGED? WILL YOU CLAIM THESE INFANTS ON YES NO X THE CACFP? - . 14.METHOD BY WHICH MEALS WILL BE PROVIDED 15. ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH I PREPARATION AT FEEDING LOCATION YES NO PREPARATION AT CENTRAL KITCHEN 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOP (WHEN YOU HAVE MORE THAN ONE SITE; ___x . UNDER o IDV OF CONTRACT)T WI H LOCAL SCHOOL SYSTEM EACH MEAL? UNDER CO TRACTRWITH FOOD SERVICE CATERER YES X NO (S OF17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perfoml Child and Adult Care Food Program food service functions in this center. ) NUMBER OF NAME OF PERSON SPECIFIC CACFP STAFF IN ' NAME OF POSITION FOOD SERVICE DUTIES THIS POSITION' As required per District Contract Teacher/Teacher Ass_stant located on site serving children fnod 4 Lunch Aide located nn site .servinn rhildrnn fnna 2 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) _PRICING(Please contact our office for further Instructions at 6). X NONPRICING In a pricing program,centers establish a charge chuck a from tuiton for meals in order to make up the difference between the reimbursement provided by the CACFF actual cost of serving the meals.In a norprlang plan,families pay a general tuition charge that covers as areas of child care services provided by the center,nclk meals.There is no identifiable separate charge for meals served to any children in care. 19.All participating centers or sponsors are eligible to receive advance payments.Advances am requested monthly by filling out an advance form.T. amount of advance money shall not exceed a typical month's rate of reimbursement and shall be deducted from that month's claim for reimburse' 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOC HOUSING AUTHORITY DATA,ETC.IN ADDITION,N,GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF*YOUR CURRENT ENROLLMENT. ESTIMATE NOTE American Indian or Alaskan Native 1% Asian or Pacific Islander 14 Actual varies according to Black(not of Hispanic origin) 3% Hispanic 70° Program Head Start vs Mier White (not of Hispanic origin) 25° Head Start in the group to which he or she to*Visual s wrikstian may be used community n or sponsors to Parents/ivardians may beetermine the child's diasked o IdenttiN ractl�c hnic category.A child may be grop of their own child a ter i has beeen expprsi� te Identities wun,er is nxhmed r a the of i as belons omleti n l e strictly for statistical _ reporting u%ell as we understand that nder Vie Program.As new children aren oenrolled,You will reed to determine eel 1 raclaiNnnic background and keep this 1 fnfornetlon In a confidential)place. receive CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 9?1.017 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6.00 YOU CAA INFANTS OE OR SPECIAL L NEEDSGULAR BASIS? YES I CMilliken WILL YOU CLAIM THESE CHILDREN/INFANTS 300 Broad ON THE CACFP? —x — TMiPlFI NHig &'( 583 )80530 587-2888 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YESx_N E E U Shin care means that children are coming and going at as times of the day s COUNTY: W e 1 d total number of children attending the center on a daily basis may exceed thv capacity. Double Sessions 2. NAME AND TITLE OF CONTACT PERSON AT CENTER 8.HOURS OF OPERATION To Be Hired FROM 7 : 00 am TO 5 : 00 pm 3. x HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATI: ac-MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 2 HOW MANY ARE AM?___.2-HOW MANY ARE PM? 7 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING 9/1 ENDING 5/3 1 NUMBER OF CHILDREN IN EACH CLASSROOM Is your Head Start site licensed as a child care center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM W of Social Services during times when Head Start is not in session? AND SNACKS FOR REIMBURSEMENT YES X NO (Include dates c closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN N/A FROM 4 TO 5 5.DO YOU CARE FOR INFANTS FROM BIRTH YES Nit 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNE THROUGH 12 MONTHS? CHANGED? WILL YOU CLAIM THESE INFANTS ON YES NO x THE CACFP? '- 14.METHOD BY WHICH MEALS WILL BE PROVIDED 15. ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EAC PREPARATION AT FEEDING LOCATION YES___x_NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN I ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT x (SUB COPY NT CONTRACT) WITH LOCAL SCHOOL SYSTEM EACH MEAL? YES x NO (SUBMIT N UNDCOPER CO TOFRANC1TRWITH FOOD SERVICE CATERER 17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this cente: NUMBER C: NAME OF PERSON SPECIFIC CACFP STAFF II, NAME OF POSITION NAME SERVICE DUTIES THIS POSITI: As required per District Contract Teacher/Teacher Assistant located on site sor-silaq children food 4 Lunch Aide located on site serving children food 2 18, IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING (Please Pile a contact our office for further Instructions at x 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 CA actual cost of serving the meals.In a nawridrg program.families pay a general trillion charge that covers all areas of child care services provided by the center,r meals.There is no identifiable separate charge for meals served to any children in care. ces are ce forrr 19.All participatingnoance sponsors hall are eligible t to month's rate reiive advance mbursemenents. t and shall be requested e deducted from that month's claim fort reimbu• amount of advance money shall not exceed a typical _ 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SC. HOUSING AUTHORITY DATA,ETC.IN ADDITION.GIVE THE ACTUAL RACIAUETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL' American Indian or Alaskan Native 1.$ Asian or Pacific Islander 1% Black(not of Hispanic origin) 1% Hispanic 7 0% While (not of Hispanic origin) 2 5% 'Visual identification may be used by centers or sponsors to determine the child's raciaVethnic category.A clad may be included in the grow to which he or she appears tc identifies with,or is regarded in the community as belonging.Parents/Guardians may be asked to identify the raceterhnc group of their own child alter it has been explain;well as we understand that the collodion of this on of their eliglady to under the Program.As new children are enrolled, t statistical the l you determine will need totha 1 raclaiSmin background and keep this information in confidential place. rec. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT S71 gin COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YES NO Jefferson CHILDREN/INFANTS ON A REGULAR BASIS? x 1315 4th Avenue WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? Greeley, CO 80631 TELEPHONE NO.: ( 3O3 ) 356-74O8 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES_c_NO COUNTY: W P] d Shift care means that children are coming and going at all times of the day so that the total number of children attending the center on a daily basis may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER H. Double Sessions 8.HOURS OF OPERATION Delia Vasquez FROM 7 : 00 am TO 5 : OO pm 3..—Z.HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING __X.MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR 50 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? HOW MANY ARE AM?_2_HOW MANY ARE PM? 2 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING 10/1 ENDING 9/31 NUMBER OF CHILDREN IN EACH CLASSROOM 1 R Is your Head Stan site licensed as a child care center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during times when Head Start is not n session? AND SNACKS FOR REIMBURSEMENT YES x NO (Include dates of closing and reopening) 4. AGE RANGE OF ENROLLED CHILDREN FROM n TO 5 N/A 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? __l^ CHANGED? WILL YOU CLAIM THESE INFANTS ON THE CACFP? YES NO x 14.METHOD BY WHICH MEALS WILL BE PROVIDED ' 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? PREPARATION AT FEEDING LOCATION YES x NO PREPARATION-AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR x UNDE R cCONTRACT OF RWITHLOCALSCHOOLSYSTEM EACH MEAL? (SUBMIUNDER CONTRACT WITH FOOD SERVICE CATERER YES x NO (SUBMIT COPY OF CONTRACT) 17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN iN THIS FOOD SERVICE DUTIES THIS POSITION POSITION As required per District Contract Teacher/Teacher Aide located on site serving children food 4 vary Lunch Aide located on cite serv4rg ohild.e-c-1, feed 2 vary 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) _PRICING(Please contact our office for further Instructions at 692-2330) x NONPRICING In a pricing program,centers establish a charge separate tmm 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 norpndrg 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. 19.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. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA. HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL *+r*NOTE American Indian or Alaskan NatNe 1% Asian or Pacific islander 18 Actual varies according to Hia of Hispanic origin) 3% Program. Head STart vs Migrant Hispspanicis 7 0� 4 g White (not of Hispanic origin) 25% Head Start 'Visual Identification may be used by carters or sponsors 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 racllelhnc group of their own child after it has been explained,and they as well as we understand that the collection of this information is strictly for statistical reporting requirements and has no effect on the deternlnarion of their elgbility to receive benefits under the Program.As new children are enrolled,you will need to determine their racial/ethnic background and keep this Information in a confidential place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 931018 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YES NO Island Grove CHILDREN/INFANTS ON A REGULAR BASIS? x WILL YOU CLAIM THESE CHILDREN/INFANTS 119 14th Avenue ONTHECACFP? Greeley, CO 80631 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES x NO TELEPHONE NO.: ( -4n z) z S?-?F?7 Shift care means that children are coning and going at all times of the day so that the COUNTY: W o 1 d total number of children attending the center on a daily basis may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER rapetly. D o b lie C e s s i o n s ._ 8.HOURS OF OPERATION Teresa Gutierrez FROM 7 . 00 am TO 5 : 00 on 3. _HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING x MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR 3 8 HOW MANY HEAD START CLASSROOMS DO YOU HAVEv 1 HOW MANY ARE AM?_L-HOW MANY ARE PM? 1 11. ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? 1 R STARTING 10/1 ENDING 9/3 1 NUMBER OF CHILDREN IN EACH CLASSROOM Is your Head Start sue licensed as a dsld late center by the Colorado Department 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during tunes when Head Stan a not In session? AND SNACKS FOR REIMBURSEMENT YES x_NO_ (Include dates of dosing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN N/A FROM 4 TO S 5. DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER • THROUGH 12 MONTHS? -x- CHANGED? WILL YOU CLAIM THESE INFANTS ON YES NO x THE CACFP? 14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? PREPARATION AT FEEDING LOCATION YES x NO (PWRFIEN YOU HAVE MORCENTRAL NSKTE)CHEN 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR x UNDMER CONTRACT IT COPY RiT WITH LOCAL SCHOOL SYSTEM EACH MEAL? YES x NO UNDER CONTRACT WITH FOOD SERVICE CATERER (SUBMIT COPY OF CONTRACT) 17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF FOOD SERVICE DUTIES THIS POSITION POSITION As required per District Contract Teacher/Teacher Ass_stant located on site serving children fnnd 2 v.mr_l Lunch Aide located on site Serving children -Food 1 vary+ 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) _PRICING(Please contact our office for further Instructions at 692-23l,) __x_NONPRICING In a pricing program,centers establish a charge generate 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 nonpidng program,families pay a general tuulon 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 n care. 19.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. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA. HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIALJETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL American Indian or Alaskan Native t$ Asian or Pacific Islander .L$ Black(not of Hispanic origin) 3%Hispanic 7 O White (not of Hispanic origin) 2 5 'Visual Mortification may be used by carters or sponsors to determine the child's racial/ethnic category.A child may be included In the group to which he or she appears to belong. ide o Ity the racial/ethnic well has we understand or is regardedthe in the�nroof f this inforas mation is striging. ctly In reporting ts/Guardians may be asked trequ ements and has no group ffe on theadetermination of their eligibil own child after it has been ity to receive benefits they underunder the Program.As new children are enrolled,you will need to determine their racial/ethnic background and keep this Information Ina confidential place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 931018 COLORADO DEPARTMENT OF HEALTH CHILD tk ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CHILDREN/EIN FORRS ON SPECIAL GULARNEEDS BASIS? YES NO Hudson 300 Beach WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? x Hudson , CO 80642 TELEPHONE NO.: ( 3 0 3) 5 3 6-04 4 0 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES x NO Shift care means that children are coning and going at all times of the day so that the COUNTY: W e 1 d total number of children attending the center on a daily basis may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER reparay. Double Sessions _ • 8.HOURS OF OPERATION Nelly Macias FRAM 7 : 00 am TO 5 : 00 pm 3. x HEAD START PROGRAM 9. NUMBER OF OPERATING 10.NUMBER OF OPERATING x MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR 5 0 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 2 HOW MANY ARE AM?__2-HOW MANY ARE PM? 7 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING 10/1 ENDING 9/31 NUMBER OF CHILDREN IN EACH CLASSROOM—1-5_ Is your HeadStart site licensed attached care center by the Colorado Department 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during times when Head Stan Is not in session? AND SNACKS FOR REIMBURSEMENT YES X NO (Include dales of closing and reopening) 4. AGE RANGE OF ENROLLED CHILDREN FROM 0 TO S M n 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER I THROUGH 12 MONTHS? x CHANGED? WILL YOU CLAIM THESE INFANTS ON YES NO THE CACFP? x 14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? PREPARATION AT FEEDING LOCATION YES___y NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR x UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMIT COPY OF CONTRACT) YES X NO UNDER CONTRACTOFRWI H FOOD SERVICE CATERER (SACT) 17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS NAME OF PERSON SPECIFIC CACFP STAFF IN IN THIS NAME OF POSITION FOOD SERVICE DUTIES THIS POSITION POSITION As required per District Contract Teacher/Teacher Assistant located on site serving children fond _ 4 wary Lunch Aide located on site serving_ rill ldren fond 7 vary 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING(Please contact our office for further Instructions at 692-2330) —7—NONPRICING In a pricing program,centers establish a charge generate 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 nonpndng 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. ents.Advances are 19 All amount of advance centers shall not exceedrs are eligible typical month'svance ra a of reimbursement and shall beudeducted from that filling nth's claim for reimbursement. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA. HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAUETH IIL BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL American Indian or Alaskan Native }1 ***NOTE Asian or Pacific Islander Black(not of Hispanicongln) 3% Actual varies according to Hispanic 70° Program Head Start vs Migrant While (not of Hispanic origin) 25% Head Start 'Visual identification may be used by centers or sponsors to determine the child's racial/ethinic category.A child may be included in the group to which he or she appears to belong. - identifles with.Of is regarded in the community as belonging.Parents/Guardians may be asked to identify the racial/ethnlo group of their own child after it has been explained.and they as well as we understand that the collection of this information is strictly for statistical repotting requirements and has no effect on the determination of their eligibility to receive benefts under the Program.As new children are enrolled,you will need to determine their racial/ethnic background and keep this Information in a confidential place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 431O1f1 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YES NO CHILDREN/INFANTS ON A REGULAR BASIS? — Gilcrest WILL YOU CLAIM THESE CHILDREN/INFANTS 1175 Birch ON THE CACFP? x — Gilcrest, CO 80623 7,DO YOU CARE FOR CHILDREN IN SHIFTS? YES�rr._NO TELEPHONE NO.: ( Z O ) 7 3 7—2 7 7 4 Shift care means that children are coming and going at all times of the day so that the COUNTY: We 1 d total number of children attending the center on a daily basis may exceed the license 2.NAME AND TITLE OF CONTACT PERSON AT CENTER capacb' 8.HOURS OF OPERATION Dorothy Perez FROM 7 : 00 am TO 5 : 00 pm 3, x HEAD START PROGRAM 9.NUMBER OF OPERATING 10. BE PO R NUMBER F OPERATING 7 _.MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 HOW MANY HEAD START CLASSROOMS DO YOU HAVE?-2- HOW MANY ARE AM? _HOW MANY ARE PM? 7 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING 9/1 ENDING 5/3 1 NUMBER OF CHILDREN IN EACH CLASSROOM _1.5— Is your Head Stan see licensed as a child tare center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during tunes when Head Start Is not in session? AND SNACKS FOR REIMBURSEMENT YES?{ NO (Include dates of closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN FROM 4 TO S N/ 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER I THROUGH 12 MONTHS? -- ac— CHANGED? WILL YOU CLAIM THESE INFANTS ON YES NO x THE CACFP? -- 14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? PREPARATION AT FEEDING LOCATION YES x NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR x UNDER MIT COPY COTOFRARCTIW H LOCAL SCHOOL SYSTEM EACH MEAL? (SUUNDER TRANTaAWITH FOOD SERVICE CATERER YES x NO OF17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS SPECIFIC CACFP STAFF IN IN THIS NAME OF POSITION NAME OF PERSON FOOD SERVICE DUTIES THIS POSITION POSITION As required per District Contract vary Teacher/Teacher Assistant located at sitq serving nhilArnn cnta4 4 serving children food 2 vary Lunch Aide T.nrat Pr3 nn cii-o 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) g_PRICING HOCING(Ple(Please contact our office for further Instructions at 692-2330) n the provided by the FP and actual aring progra etme is In a a charge rame from tuition for meals In.lamities pay a general Naionr io make up the dMerence ciarge tthat covers all areas of child care seery ces provided by the cen er,mtlud ng ttw mels cost rofe serving the meets.pn a to har a orog meals:There is no identifiable separate charge for meals served to any children in care. 19.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. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA. HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL ****NOTE American Indian or Alaskan Native Asian or Pacific Islander 1% 1% Black(not of Hispanic origin) /3% Hispania /5% White (not of Hispanic origin) 'visual identification may be used by centers or sponsors to determine the chiles raciayethnic category.A chid may be included in the group to which he or she appears to belong, identifies with.or s regarded in the community as belonging.Parents/Guardians may be asked to identify theirir own chlretnth r it i their been ex explained, receive ar they as s well as we understand that the collection of this intonretion le strictly for sretlstical repotting requirements and has no effect on the under the Program.As new children are enrolled,you will need to determine their radaVetMlo badtground and keep this Information In a confidential Mace. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 4:31019 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YES NO Frederick CHILDREN/INFANTS ON A REGULAR BASIS? -_2(._ WILL YOU CLAIM THESE CHILDREN/INFANTS 340 Maple ON THE CACFP? X Frederick , CO 80642 • 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES x NO TELEPHONE NO.: ( zn� ) R73-?7�n Shift care O mean that ch I are toning and TS at all times of the day Nso that the COUNTY: W e 1 d total number of children attending the center on a daily basis may exceed the license 2.NAME AND TITLE OF CONTACT PERSON AT CENTER capacity. Double Sessions ._ 8.HOURS OF OPERATION To Be Hired FROM 7 : 00 am TO 5 : 00 p.m 3, AHEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING x MIGRANT HEAD START PROGRAM • DAYS PER WEEK 5 WEEKS PER YEAR 5 0 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 1 HOW MANY ARE AM? ._HOW MANY ARE PM? 1 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING 10/1 ENDING 9/3 1 NUMBER OF CHILDREN IN EACH CLASSROOM---1-5-- Is your Heed Start site licensed as a Wild care center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during times when Heed Stan is not In session? AND SNACKS FOR REIMBURSEMENT YES}L NO_ (Include dates of closing and reopening) 4. AGE RANGE OF ENROLLED CHILDREN N/A FROM 0 TO 5 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13.. HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER l THROUGH 12 MONTHS? -� CHANGED? WILL YOU CLAIM THESE INFANTS ON YES NO X THE CACFP? ___x___ 14. METHOD BY WHICH MEALS WILL BE PROVIDED 15. ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? PREPARATION AT FEEDING LOCATION YES X NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR x UNDER O CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMIOF CONTRACT) YES x NO UNDER CONTRACT WITH FOOD SERVICE CATERER (SUBMIT COPY OF CONTRACT) 17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN .N THIS FOOD SERVICE DUTIES THIS POSITION POSITION As required per District Contract i mAachar/Teacher Aide located on site serving children fond 2 vary Lunch Aide located on site nerving children food I vary 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) X PRICING NONPRICINGle a contact our office for further Instructions at 692-2)30) in a pricing program,centers establish a charge wmerate from tugion 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 norpridrg program,families pay a general tuition charge that covers aN 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. 19.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. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA, HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAL/ETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL *** NOTE American Indian or Alaskan Native 1% Asian or Padfic islander 1% Actual varies according to Black(not of Hispanic origin) /3% Program Head Start vs Migrant Hispanic Head Start White (rot of Hispanic origin) 1 S£ 'Visual identification may be used by certers or sponsors to determine the child's racaVethnic 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.Parentseuardians may be asked to identify the raciaVdhnic group of their own child after it has been explained,and they as well as we understand 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 detsrmine their radalethnic background and keep this Information In a confidential pace. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 931018 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YES NO CHILDREN/INFANTS ON A REGULAR BASIS? x East Memorial WILL YOU CLAIM THESE CHILDREN/INFANTS 614 E. 20th Street ONTHECACFP? x Greeley, CO 80631 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES x NO TELEPHONE NO.: ( 303 ) 352-9478 Shift care O means that ch I are CHILDREN and TS at all times of the day Nso that the CAUNTY: W e 1 d total number of children attending the center on a daily basis may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER o cm'- Doub1 e Secs innC 8.HOURS OF OPERATION Annette Sandoval-Cline FROM 7 • nn a m TO S - n0 r m _ 3. S HEAD START PROGRAM 9.NUMBER OF OPERATING 10.NUMBER OF OPERATING x MIGRANT HEAD START PROGRAM DAYS PER WEEK S WEEKS PER YEAR 5 D HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 2 HOW MANY ARE AM?_......2-HOW MANY ARE PM? 2 11. ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING 1n/1 ENDING Q/3 1 NUMBER OF CHILDREN IN EACH CLASSROOM_1.5_ Is your Head Start site licensed as chlkl rare center by the Colorado Department 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during times when Head Start is not in session? AND SNACKS FOR REIMBURSEMENT YES x NO (Include dales of closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN FROM n TO 5 N/A 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER I THROUGH 12 MONTHS? x CHANGED? WILL YOU CLAIM THESE INFANTS ON x YES NO X THE CACFP? 14. METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? PREPARATION AT FEEDING LOCATION YES x NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR X UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMIT COPY OF CONTRACT) YES x NO UNDERT CO TOFRACTRWITH FOOD SERVICE CATERER 17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN IN THIS FOOD SERVICE DUTIES THIS POSITION POSITION As required per District Contract Teacher/Teacher Assistant located on site serving children food 4 vary Lunch Aide located on site serving children food 2 vary 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING (Please contact our office for further Instructions at 692-2330) --5r- G In a pricing program,centers establish a charge venmate 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 norpncirg 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. 19.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. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA.PUBLIC SCHOOL DATA, HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIAUETHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL * *NOTE : American Indian or Alaskan Native 1 Asian or Pacific Islander 1% Actual varies according to Black(not of Hispanic origin) 3$Hispanic / Program Head STart vs Migrant % Head Start While (not of Hispanic origin) 25 'Visual identification may be used by centers or sponsors to determine the child's racial/ethnic category.A child may be included in the group to which he or she appears to belong, well w as wwith, unders aM�hatttthem the collection community WMreati Is strictly N�atical reporting f may be asked to req requirements and has racial/ethno group fe on tthheedetermination of tfa�irl el�igibillity to receeive bens under the Program.As new children are enrolled,you will need to determine their racial/ethnic background and keep this Information in a confidential place. CACFP-301 (4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 931018 COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER(FEEDING LOCATION) 6.DO YOU CA FS ON X RE FORSPECIAL REGULAR BASIS? YES NO CHILDREN/Dos Rios WILL YOU CLAIM THESE CHILDREN/INFANTS x 2201 34th Street ONTHECACFP? — Evans , CO 80620 TELEPHONE NO.: ( 330-3220 7.00 YOU CARE FOR CHILDREN IN SHIFTS? YES x NO Shi3 0 3 ) T DO care means thatchildren are coming and going at all times of the day Nso that the COUNTY: Weld total number of children attending the center on a dairy basis may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER caParty. Double Sec c i n n s 8.HOURS OF OPERATION Patricia Sandoval FROM 7 : 00 am TO 5 . 00 p in 3. x HEAD START PROGRAM 9.NUMBER OF OPERATING 10.NUMBER OF OPERATING _X MIGRANT HEAD START PROGRAM DAYS PER WEEK 5 WEEKS PER YEAR S 0 HOW MANY HEAD START CLASSROOMS DO YOU HAVE?-2-- HOW MANY ARE AM? 2 HOW MANY ARE PM?-.2-- 11. ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? STARTING 10/1 ENDING q/7 1 NUMBER OF CHILDREN IN EACH CLASSROOM Is your Head Stan site licensed as a child rare center by the Colorado Department 12. LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during times when Head Stan is not in session? AND SNACKS FOR REIMBURSEMENT YES X NO_ (Include dates of closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN FROM 0 TO S N/A 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. . HAS THE D?NAME OF THE CENTER OR SPONSOR OR OWNER I THROUGH 12 MONTHS? XL CHANGE WILL YOU CLAIM THESE INFANTS ON YES NO X THE CACFP? x 14.METHOD BY WHICH MEALS WILL BE PROVIDED 15.ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? PREPARATION AT FEEDING LOCATION YES X NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR X UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMIT COPY OF CONTRACT) YES X NO UNDMER CO IT COPY OF CT WITH FOOD SERVICE CATERER (SUBACT) 17. FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN IN THIS FOOD SERVICE DUTIES THIS POSITION POSITION As required per District Contract Teacher/Teacher Assistant located nn site serving children food 4 vary Lunch Aide located on site serving children food 2 vary 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) PRICING (Please contact our office for further instructions at ego-l)3u) ING In a pricing program,centers establish a charge generate 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 nonpridrg 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. 19.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. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE HOUSING AUTHORITY DATA.ETC..IIN ADDITION,GIVE THE ACTUAL RACIA CIAUETHNIC MAKEUP OF THE EUET NIIC BREAKDOWN OF N TO BE SERVED FROM SOURCES CURRENT ENROLLMENT.DATA,PUBLIC SCHOOL DATA, ESTIMATE ACTUAL ****NOTE : Actual varies American Indian or Alaskan Native 1% Asian or Pacific Islander 1 % according to Program Head Start Black(not of Hispanic origin) "I& vs Migrant Head Start Hispanic 7 0% White (not of Hispanic origin) 7 5 a • 'Visual identification may he used by centers or sponsors 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 race&ethnlc group of their own child after it has been explairedd,and they as well as we urderstannd that the collection of this iNormation Is strictly for ah lseral 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 determine their racial/ethnic background and keep this Infornatlon Ina confidential place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 93101N COLORADO DEPARTMENT OF HEALTH CHILD&ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6. DO YOU CARE FOR SPECIAL NEEDS YES NO CHILDREN/INFANTS ON A REGULAR BASIS? X Centennial WILL YOU CLAIM THESE CHILDREN/INFANTS 400 37 h Street ON THE CACFP? X vans , TELEPHONE NO.: ( 301 ) 339_3085 7.DO YOU CARE FOR CHILDREN IN SHIFTS? YES_]LNO Shpt care means that children are coming g and going at all times of the thy so that the COUNTY: Weld total number of children attending the center on a daily basis may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER caPacdY. Double Session 8.HOURS OF OPERATION Delia Vasquez FROM 7 : 00 a.m. TO 5 : 00 P .m- 3. _x_HEAD START PROGRAM 9.NUMBER OF OPERATING 10. NUMBER OF OPERATING -X MIGRANT HEAD START PROGRAM DAYS PER WEEK S WEEKS PER YEAR Sp HOW MANY HEAD START CLASSROOMS DO YOU HAVE?—.2— HOW MANY ARE AM? 2 HOW MANY ARE PM? 2 11. ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY?_ STARTING 10/1 ENDING 9/3 1 NUMBER OF CHILDREN IN EACH CLASSROOM 15 Is your Head Stan site Ilcensed as a child care center by the Colorado Department 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during times when Head Stan Is not n session? AND SNACKS FOR REIMBURSEMENT YES X NO (Include dates of closing and reopening) 4.AGE RANGE OF ENROLLED CHILDREN FROM 0 TO S n/a 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER I THROUGH 12 MONTHS? �_ CHANGED? WILL YOU CLAIM THESE INFANTS ON YES NO X THE CACFP? s 14.METHOD BY WHICH MEALS WILL BE PROVIDED 15. ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? _ PREPARATION AT FEEDING LOCATION YES X NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR X UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMIT COPY OF CONTRACT) UNDER CONTRACT WITH FOOD SERVICE CATERER YES X NO (SUBMIT COPY OF CONTRACT) 17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN IN THIS FOOD SERVICE DUTIES THIS POSITION POSITION As required per District Contract Teacher/Teacher Assistant located on G; FA Carving children food 4 vary Lunch Aide located on site serving children food 7 vary 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) _PRICING(Please contact our office for further Instructions at 692-2330) X NONPRICING In a pricing program,centers establish a charge somata 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 nanpridng program,families pay a general tuition charge that covers as areas of child care services provided by the center.including meals.There is no identifiable separate charge for meals served to any dudren in care. 19.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. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAUETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS 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 1% ***NOTE : Actual varies according Asian or Pacific Islander 1% to Program Head Start Black(not of Hispanic origin) 3$ vs Migrant Head Start Hispanic 70 White (not of Hispanic origin) 2 S% 'Visual identification may be used by centers or sponsors to determine the child's racial/ethnic category.A child may be included in the group to which he or she appeals 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 chill after it has been eulained,and they as wet as we understand that the collection of this information Is strictly for statistical reporting requirements and has no effect on the determination of their eligbility to receive benefits under the Program.As new children are enrolled,you will need to determine their racial/ethnic background and keep this Information In a confidential place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 931018 COLORADO DEPARTMENT OF HEALTH CHILD &ADULT CARE FOOD PROGRAM APPLICATION FOR CHILD CARE CENTER 1.NAME AND ADDRESS OF CENTER (FEEDING LOCATION) 6.DO YOU CARE FOR SPECIAL NEEDS YES NO Billie Martinez CHILDREN/INFANTS ON A REGULAR BASIS? x 341 14th Avenue WILL YOU CLAIM THESE CHILDREN/INFANTS ON THE CACFP? x Greeley, CO 80631 TELEPHONE NO.: ( 30 3 ) 3 5 1-0 312 7. DO YOU CARE FOR CHILDREN IN SHIFTS? YESa_NO COUNTY: We 1 d Shift care means that children are coming and going at all times of the day so that the total number of children attending the center on a daily basis may exceed the license 2. NAME AND TITLE OF CONTACT PERSON AT CENTER caPacilY. Double Session .- B.HOURS OF OPERATION • Lorraine Venzor FROM 7 : 00 am To 5 : 00 p.m. 3. mot_HEAD START PROGRAM 9.NUMBER OF OPERATING 10.NUMBER OF OPERATING x MIGRANT HEAD START PROGRAM DAYS PER WEEK S WEEKS PER YEAR 5 0 HOW MANY HEAD START CLASSROOMS DO YOU HAVE? 2 HOW MANY ARE AM?_2_____HOW MANY ARE PM?_2____ 11.ANNUAL DATES OF OPERATION HOW MANY ARE FULL DAY? ki STARTING 10/1 ENDING September 31 NUMBER OF CHILDREN IN EACH CLASSROOM Is your Head Stan site licensed ass child rare center by the Colorado Drrparintere 12.LIST ANY MONTHS DURING WHICH YOU WILL NOT CLAIM MEALS of Social Services during times when Head Start is not in session? AND SNACKS FOR REIMBURSEMENT YES_NO_ (Include dates of closing and reopening) 4. AGE RANGE OF ENROLLED CHILDREN FROM 0 TO 5 N/A 5.DO YOU CARE FOR INFANTS FROM BIRTH YES NO 13. .HAS THE NAME OF THE CENTER OR SPONSOR OR OWNER THROUGH 12 MONTHS? x CHANGED? WILL YOU CLAIM THESE INFANTS ON YES NO x THE CACFP? ._t- 14.METHOD BY WHICH MEALS WILL BE PROVIDED 15. ARE MEAL PRODUCTION RECORDS BEING KEPT FOR EACH MEAL? PREPARATION AT FEEDING LOCATION YES NO PREPARATION AT CENTRAL KITCHEN (WHEN YOU HAVE MORE THAN ONE SITE) 16.ARE RECORDS OF MEALS SERVED FORMS BEING KEPT FOR x UNDER CONTRACT WITH LOCAL SCHOOL SYSTEM EACH MEAL? (SUBMIT COPY OF CONTRACT) UNDER CONTRACT WITH FOOD SERVICE CATERER YES x NO (SUBMIT COPY OF CONTRACT) 17.FOOD SERVICE STAFF PATTERN(Only enter staff who will perform Child and Adult Care Food Program food service functions in this center.) NUMBER OF YEARS NAME OF POSITION NAME OF PERSON SPECIFIC CACFP STAFF IN IN THIS FOOD SERVICE DUTIES THIS POSITION POSITION As required per District Contract Teacher/Teacher Ass_stant located on site serving children food 4 vary Lunch Aide located on site serving children food 2 vary 18. IS THIS A PRICING OR NONPRICING PROGRAM?(CHECK ONE) _PRICING(Please contact our office for further instructions at 692-2330) X NONPRICING In a pricing program,centers establish a charge seoargic+fmm 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 norpnang program,families pay a general tuition charge that covers all areas of child care services provided by the center,including meale.There is no identifiable separate charge for meals served to any children in care. 19.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. 20.CIVIL RIGHTS PROVIDE AN ESTIMATE OF THE RACIAL/ETHNIC MAKEUP OF THE CHILDREN TO BE SERVED FROM SOURCES SUCH AS CENSUS DATA,PUBLIC SCHOOL DATA, HOUSING AUTHORITY DATA,ETC.IN ADDITION,GIVE THE ACTUAL RACIALJEfHNIC BREAKDOWN OF YOUR CURRENT ENROLLMENT. ESTIMATE ACTUAL **NOTE : Actual varies according Amencan Indian or Alaskan Native 1% Asian or Pacific Islander 1% tO Program Head Start Black(not of Hispanic origin) 3$ vs Migrant Head Start Hlspartic /0% White (not of Hispanic origin) 25% 'Visual identitkation may be used by centers or sponsors to determine the child's raaal/elhnic 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/Guaniiens may be asked to identify the racial/ethnic group of their own child alter it has been explained,and they as wet as we understand 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 determine their racial/ethnic background and keep this Information In a confidential place. CACFP-301(4/93) WHITE-CDH-CACFP YELLOW- APPLICANT 911018 mEmoRAnDum Board of County Commissioners s5 Constance L. Harbert Sept. 27, 1993 To Date b �/�W Walter J. Speckman, Executive Director, Human-,Re4qurcp�� COLORADO From Purchase of Service Agreement between FENWC and Child and Subject: Enclosed for signature is an agreement between the Colorado Department of Health, Child and Adult Care Food Program and the Family Educational Network of Weld County, for reimbursement to FENWC of meals served to children. This is an on-going Agreement. If you have any questions please call Tere Keller-Amaya at extension 3342. 941018 Hello