HomeMy WebLinkAbout972190.tiff- .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
RESOLUTION
RE: APPROVE RENEWAL FORM FOR CHILD AND ADULT CARE FOOD PROGRAM
AGREEMENT AND AUTHORIZE CHAIR 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 Renewal Form for the Child and Adult
Care Food Program Agreement between the County of Weld, State of Colorado, by and
through the Board of County Commissioners of Weld County, on behalf of the Department of
Human Services, Family Educational Network of Weld County, and the Colorado Department of
Public Health and Environment, commencing October 1, 1997, and ending September 30,
1998, with further terms and conditions being as stated in said form, and
WHEREAS, after review, the Board deems it advisable to approve said form, 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 Renewal Form for the Child and Adult Care Food Program
Agreement between the County of Weld, State of Colorado, by and through the Board of
County Commissioners of Weld County, on behalf of the Department of Human Services,
Family Educational Network of Weld County, and the Colorado Department of Public Health
and Environment be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said form.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 6th day of October, A.D., 1997 nunc pro tunc October 1, 1997.
BOARD OF COUNTY COMMISSIONERS
% WELD OUNTY, C ORAD
ATTEST: g l Fli
4axterf
Chair
Weld County sler t 117'
it
i � Constance L. Harbert, Pro- em
BY:
Deputy Clerk to th- EXCUSED DATE OF SIGNING (AYE)
Dal K. Hall
flA7/ORM: LAQ_
arbara J. Kirkmeyer
my Atto (' // \ 101
W. Ff. WebsterV
972190
(� : /15 ST
H R0068
cMa&.Adus Fond Prog;amj
AUDIT QUESTIONNAIRE
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 or business office,or
someone on your board who is familiar with auditing procedures,prepare this questionnaire.
Center/Sponsoring
eld County Division of Human SerAgreementNumber: 65103-05 Organization: 1/
Services ' Family Educational Network of Weld County
Address: 1551 N 17 Avenue , P .O. Box 1305
Greeley CO 8063.2
1. Do you contract*with an accounting firm to conduct an audit of
your center/sponsoring organization? Yes x No
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. J
3. Is a review of the CACFP included in that organization-wide audit? Yes x No
4. What is the legal name of the organization being audited?
Weld County Division of Human Services
5. What federal funds does your organization receive other than CACFP?
(Examples:National School Lunch Program,Title XX)
Region VIII Head Start $ 1 . 5 Million
Region XII Migrant Head Start $ 1 .4 Million
$
$
6. What is the total annual budget for the organization identified in Question#4?
(include all federal,state,and"other" funds) $ 6 , 000 , 000. 00
7. When does your organizations's fiscal year begin and end?
January 1st through December 31st
8. Does your organization have fiscal year end schedules(financial statements)? Yes x No
9. Does you organization have computerized records? Yes x No
gy ¢G� , k , fy3. , tom$.s p " HZrH .Cl ' t£6 8t i" £ H \t $ ®- Y P $i ce
• Questionnaire prepared by cr✓-C Y I [12 fr" /t-vr114- Date:
Title: )i1-c ✓ Phone Number: ( )3S 3 0u
(CDPHE-CACFP 7/96 cAFormsVwditQue.PMS) " 33 {t
414
;clap .�s e , e' °e a3 B ¢ i
This Certification is given by the Contractor in compliance with regulations implementing Executive
Order 12549, Debarment and Suspension, 7CFR Part 3017, Section 3017.510. The Contractor hereby
certifies,by execution of the contract,that neither it nor its principals is presently debarred, suspended,
proposed for debarment,declared ineligible or voluntarily excluded from participation by any federal
department or agency.
Renewal New Center
Child&Adult Care Food Program
SPONSOR OF CENTERS APPLICATION
1. Name of Sponsoring Organization: Family Educational Network of Weld County
Contact Person: Tere Keller—Amaya
Phone Number: ( 970 1 3 5 3—3 8 0 0
2. List the number of CACFP participating centers in each category under your administration:
Nonprofit Child Care Centers Nonprofit Adult Day Care Centers
Outside-school-hours Centers For Profit Title XIX Adult Day Care Centers
For Profit Title XX Centers
12 Head Start Centers September — June
10 Migrant Head Start Centers June — September
3. List the total number of participants enrolled at CACFP participating centers under your administration:
Nonprofit Child Care Centers Nonprofit Adult Day Care Centers
Outside-school-hours Centers For Profit Title XIX Adult Day Care Centers
For Profit Title XX Centers
666 Head Start Centers
i 3 e Migrant Head Start Centers
4. Do you participate in the Colorado Preschool Project(not applicable for adult day care centers)?
Yes X No
5. Sponsors are responsible for collecting,maintaining,and reviewing the following records for each center. Please describe
the system you use for:
A. Income Eligibility Forms(IEFs):
Income Eligibility Forms are complted at the beginning of the
school year.
B. Record of Meals Served(ROMS):
Teachers complete Record of Meals Service and turn into Family
Services and the information is compiled for the Meal Claim Forms.
C. Menus:
At the beginning of the school year menus are formulated with the
appropriate school districts and approved by Parent Policy Council .
D. Production Records:
Production Records are done by the school district cooks and
reviewed by the Director.
E. Food Receipts and Invoices:
Invoices are approved by the Director and sent to the Fiscal Officer
for payment and recording purposes.
(I)
•
6. Sponsors must distribute CACFP reimbursements to centers within 5 days of receipt from CDPHE-CACFP. Please
describe how you do this:
Reimbursements are made directll ; to eld County = Individual centers
do not receive direct reimbursement .
7. All center staff who work with CACFP must receive initial training as well as annual training regarding the food program
and nutrition. Please describe how you will be training staff regarding food program recordkeeping requirements,
administrative and food service. Please include dates and topics to be covered.
Center staff will receive training on November 17th and cover
the aforementioned topics.
8. Before you bring on a new center,you will be required to conduct a preapproval visit. Please describe how you will do
this. If available,attach a copy of your preapproval evaluation form.
t will not be opening or operating new centers.
9. All centers must be visited at least three times a year with no visit being more than six months apart. Please describe how
you will meet this requirement, including who will be responsible for the visits and an approximate schedule of when the
visits will be made. If available,attach a copy of your evaluation form and your schedule for visiting centers.
The contacted nutritionist/health specialist visit the centers
3x per year on a staggered schedule — Nov. , ?!arch, August .
10. Please describe your procedure for following up on problems discovered during monitoring visits.
An action Plan is written and a follow—un visit occurs within
30 days of the date of the plan. If needed technicial assistance
is provided.
11. Will any of the centers contract with a food service management company for meals? Yes No X
If yes,please list, for each center,the contractor and the type of delivery procedure that will be used to supply meals for
the center(attach separate sheet if needed).
Food Service Management Company Food Service Management Company
Address Address
Contact Contact
(2)
•
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.)
!< y
4� t, .� 1°etcentaoeOfindlyrd:dafts s goon ACFP
a�>s tunespCR#un4*CFP F`aadedSalar1Onit
ys , ; l;"000p RPeesfy.CAO`P'DutiesN EMA #*woong PiNEMPNOOMNIM
ONOWINEMMEOROM MOOMMEONNOM MIREEMONOWN SOMMEMNIEffnmggggptegOIM
NOWIRIONWROMEMEn j
Administrator
(or equivalent)
Assistant Administrator
(or equivalent)
Clerical
(or equivalent)
Cook
Other(specify)
Total CACFP-Funded Labor$ —0—
Annual CACFP Administrative Budget(cost for CACFP related activities only)
CACFP-Funded Labor(enter total from above) $
Office Supplies(including reproduction costs)
Postage
Transportation for Facility Monitoring(include mileage multiplied by 20¢)
Telephone
Office Rental/Mortgage Payment and Maintenance
Utilities for Office Area
Other(specify)
Total CACFP Administrative Budget $ —0—
Annual CACFP Budget for Food Service Operations at Facilities under Your Administration (cost for CACFP related activities only)
Food Purchases $
Food Service Labor(salaries of staff preparing or serving meals)
Food Service Contractor Fee 130 000. 00
Nonfood Supplies(napkins,straws,dishwashing detergent,etc.) 1 . 000. 0n
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 $ 181 , 000, 00
LIST SOURCES OF CASH INCOME SPECIFICALLY FOR THE FOOD SERVICE OTHER THAN CACFP REIMBURSEMENT.
N/A
I certify that the information on this application and any other application materials 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 disability 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 by a food.service management company in compliance with CACFP regulations. I understand that this information is being given in connection with
the receipt of Federal funds and that
h^attdeliberaatte misrepresentation may subject me to prosecution under applicable State and Federal criminal statutes.
ignature of A inistrator or Authorized I',Jzjpresentative Date
(CDPHE-CACFP 302)
(CDPHE.CACFP LWEWCTR.FRMAPPISPON.Crl 6/97 DM) (3)
hit AdulfeareP be Pragcamt,
Certificate and Statement of Authority
This organization is a:
Nonprofit Organization 0 Church U For Profit Organization❑
I, (We), the undersigned, state that the child care center(s) listed on Schedule A of the
Agreement (CACFP 300) or the Multiple-Site Summary Sheet is an integral part of, and
therefore under the direct control of, the governing body of the
Weld County Division Qf Tlttman servirp 'Family ctiicationa1 MP1-wnrk of Weld county
(Name oldie Organization,Business or Church)
whose address is 1551 North 17 Avenue , P.O. Box 13f-Vt, Greeley S0C3?
(Street or Route) (City) (Zip Code)
( 970 ) 353-3Son
(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(s) appears below is authorized to sign the Claim for
Reimbursement and is fully-empowered to enter into any agreement with the Colorado Department of Public Health&
Environment 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,it shall be the responsibility of the center or sponsor to
request from this office,Colorado Department of Public Health&Environment 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.
F"oliizE ESErr ivE{s
• 1. x /14 16-1 2. .ZiA i
Signature / i signature
Tere Keller—Amara Dever y Sanchez
Print Name Print Name
Director Director of Onerations
Title Title
is the duly designated Authorized Representative(s)for the Center/Sponsor listed above.
Note: It is to your benefit to have two people designated as Authorized Representatives.
I(we) understand that the information on this form is being given in connection with the receipt of
Federal f ds and that all of the provisions of the Agreement (CACFP 300) apply.
7 Weld County Roard of Comms .
♦ / ranr�p F RaxrPr Cralrnerson
Signature of of the Board of Directors, Print Name Official Title
or Pastor,or Executive Director,or Owner
10/06/97
Date
(CDPHE-CACFP 306 7/96-a\forms\cert-soa.PMS))
Renewal Form
CDPHE-CACFP
October 1, 1997- September 30, 1998 (Annually)
Dear Center CACFP Representative:
This form reflects the most current information the Colorado Department of Public Health and Environment, Child and Adult
Care Food Program (CDPHE-CACFP) has on file concerning your center and its participation in the CACFP. Please review the
form and verify the accuracy of the information. Make the necessary corrections (in red ink) to anything that is not correct
and/or no longer applicable. Sign and return the form to the CDPHE-CACFP by September 19, 1997. If you have any
questions, please contact Wanda Unterzuber at 303-692-2346.
1.CENTER/SPONSOR INFORMATION Name and Address: FAMILY EDUCATION NETWORK
Agreement Number:65103-05 OF WELD COUNTY
PO BOX 1805
Federal Tax ID Number: 84-6000813 L GREELEY, CO 80632-1805
2. I have reviewed this form and certify that the information it contains is correct.
Print Name: Signature:
3. MAILING ADDRESS
If you would like your reimbursement check mailed to an address different from the above,your W-9 form must reflect the correct address. Call the
4. Number of Centers: 15 County: Weld y�(- N ; ��
Authorized Representative: 1.TERE KELLER-AMAYA 2.-
Center Telephone: (970)353-3800 Alternate Telephone:(970)356-0600 Fax: (970)356-3975
5. Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep
Months Approved for CACFP Participation: kgii El HI HI'4 �,r
6. Commodities:a 1 Cash-In-Lieu of Commodities: Ei
7. Number of Shifts:2 8. License Capacity: 620 9. Does center care for infants?
License Number: N/A Yes No
Bkfst AM Sn Lun PM Sn Sup Late Sn License Expiration Date: 9/30/96
Meals Approved: " ,.4 '0 ' Timely Renewal: N Does Center claim infants on the CACFP?
Hours: 6:30A-6:OOP (up to first birthday)
10. Is this a pricing program? Yes No
Days Open: MON-SAT Yes sq« , No
11.Center contracts meal service?Yes ¢`t No ' ' 12.Contractor's Name: 7 SCHOOL DISTRICTS 13. Food Service Contract Expiration
(please list additional contractors on the back) (please list additional dates on the back)
V'JLL f Date: 6/30/97
14. Meals are: Prepared at the center " Prepared off-site 15. Age Range of Participants: 0 to 5
16. FOR PROFIT CENTERS ONLY
According to our records,these are the counties your center has Title XIX or XX contracts with. Please update as necessary.
County: Expiration Date: County: Expiration Date:
County: Expiration Date: County: Expiration Date:
17. Request information on advance payments.
Step 1 -Wanda/bebbie Step 2-Specialist Follow-up Information:.-
Packet Packet Incomplete
Received: follow-up
Initial uate
m is Date
All Forms Received:
Forms Missing: Person Contacted:
Card Sent: or
Date
Form Ltr Sent Renewal complete:. Date: Initial
Date Card Sent(?)(see step 1):_already sent send
Y Y Y Y Y
CO CO CO (I) Cl)
N m a) a) m
m Cu co Cu co
J J J J J
u) to L
'a-)
M O O aM m O aM O O aM O O a0 O O
a v a e a v a .. co ..
N N N o 'f, a 0 N
C O t 0) O t CO O r CO O t CO O t
0 0 0 0 0
C 2) c 2 c m c a) C N
en� OM 2 CO oM 2 CO oM cn OM 12 N co M a
aNla. N dN 0_ NL 0. N tW O Ual a O It oUW O U wa
U
2_ o o 2 2 o 2_ o 2 o
H m H m 1,., m H m F, m
o) m rn rn ca
U) JU a.co JO JU X co JU OM J O 0M co
CC
c c c c c
W 4 � m Qc m ¢ � m a � r m ac r- m
I- ill-I 2 0) WJ CO m W- m Cn wJ 2 m W-- m m
N Q W Q 0 Q .N Q N Q
N LL C C C C C
fn 2 Y 0 0 0 Y 0 0
W c� co 2 u) 2 in 2 in 2 0) 2
I— m 2 m g `m 2 m 2 co 2 Cu
W
Q as ¢ a�a Q m Q N Q as
a` a a` 0_ a
m) N d 2 2 m
0 .E o `m o co 0 co o co w o `m
M M M Z_ M
1-- 'a Y 00 m Y 0 m Y COY 0 m J Y 0
p 0 m
Q tE CO m m m 2 J m
d a W > li
U N N CC N CC 0 a
.N w = W_ Z Jr
cc p Q t
• m N 0_ LU
n. W } co U) 0) O en Cr) COp CO(n O O
W 0)
) C W co o 2 Z O > O) CO Q O 601 F Nco ,
Q _U c') UH Q Cr) O to Cr) NIli
F- M t+)
m r M r CO J CO r CO CC OD I-IJ r M Z 1.0 r 00 M
C
2 O 0 OO O ai . . a H . . O Z p�S
W m Mo d rn oo a a) • No m y Oo -- v < coves? cia
• '- m_ .- m 0) a0'O CO p ao'O m o CO la m p co LO CO p
0 a s W as COr as W as 0as
C.) . . mX a) m .. mX a) m . . mX m m - COX m m . . mX m m
Q 4k U W OO a at U W a s xt U w OO a U W o a U W o a
I— m m m c U m m m n U a) 0) m c U m m L U a) m _c U
N N coN N N N N N N N N N N N
C C C an, C C C C' C C C a C C C a ymr C C C a CO
4 mmmC m m m m C mmm C mmm C mmm Q C
U U U m O U U U m O U U U m O V U U m O U U U m O
J JJ H U J JJ I- U J J_I I- U JJJ I- U J JJ H U
O 0 N Co 0
O d o v d
O O 0 0 0 0c N O 0 O m
elC O C C C O c c.O ma ma ma ma CIa
co ❑ ❑ ❑ "N❑ oL❑
co ~ r. c co) Fes- co
O H
CC zW _ _ _
F CO N 0 - o 2 o i J 0 CO
j W co o Co o CO 0 Q o 0 o
W Z Z W(7 W m c0 m (r H[] m U
Z N H >U 0 -I I- = (~i)o 0 = O�U 0 Y Y
OHz N w �Sw co ZHOU o OIr. c WOW o IYd2 a
U=)n0 W WVJ Lu Wc,o CD « CC co = 2NW WQW
mw_,XW -Jd.� a W�> Oo CO r> z Q�� a W0W a
N�W�w 0 (Y)MCD `m UrW c 0Nw c 111o0 c LLMLL c
o!s a]W u) co CO a) cn
c
c`ooLLOo_O
Y Y Y Y Y
CO CO CO CO CO
a) a) m N m
CO a (0 co al
J J J
u') A Lo
d re N p d CD co 00. iM O O a O O O O_ a) O
j _ 'y a. :N d .N a .N a N
V) .� 0 V) 0 CO S 0 CO 0t U) 0
Y O C s „ C Y C Y C s C
c 2) C J N C m C c' 2 C 2)
23
wa 0 wa U Ill 0_
, 0 wa O 0 wa ,Th 0
S €' w2
_ o _2 o 2 o o o
m Cl) a)I— o) F- a) m a) �" rn
c am co
Co —I c) c, Jc Jc ., K —1c oM IX J �
LU QS m Qg m Q = m ac a) Q3 m
I— wJ w 0) wJ _ 2l 0) wJ 0) wJ c- d O) WJ 2 O)
N Q N < S N Q 2 .N Q S V) Q
ill u- 0 0 0 0 0
U Y Y Y
C -p C -0 C '0 C "O C '0
U) N co 2 U) 2 U) 2 co m
I-- O g `m 2 co 2
. 2 2
Z 'C Q N Q c ¢ CON Q CON < ad
V c a a a a
a
rn ] ,_ 0 2 0
co
m N w i u! en V1 N
I— .a co J co . d m J . To a) coo al To
m m d
a• n w CC
Q O
a w
Q � en N I N m o v ti P
d :: a CZ m 11.1
rn d'`L rn N O
c rn d.. 0 CD r- Et r Z _ v co
Q U J M r 1 J -lcM p C N W
m N (O =r CO N CO W M N M [10 -N" M =
p O .. O W
W 0) P o o o NNd N <opm vac nm ° c
C O 62 O W Lo ea N N f4
c C (O m C pM m N V0 CO O O� O
J d d N O d d m p d d m N d d m a)
Q il�w o a tow o ° tow o a x* Uw g °- %0W g a
a) N N Q N N N N O. CO N fOA N Q CO N N N d N ul y N ,c t
O. m
Q C C C C C C C C C C C C C C C
a s m C a s a m C 0 00 0 N 0 a) 0 0 N 0 m m 0 N C
U V U m 0 U V U a) 0 U U U a) o U U U m O U U U m O
JJJ H 0 JJJ H 0 JJJ H 0 JJJ F- U JJJ H U
N y
coLa ca N N N N N
0 , do � o - -`a 8o
c o 5 0
0p 0 0 0 O y O 1,
Ac
C) > c > c >
p o o
o m a ea m
� ci
N' ❑ ❑ D& N OU ~ N ~ M ~
s
m CO ZZ J Co 5
2 0 c a0 c O O o Co o Wco
o
Z0 10 0 co
5 >W O
=U u 0u
u
1" ¢ c s ZZc c0>0 =
Q ZU=wZ0 �Q
CO0 jw U c CO c c a 01 a
n it,—,c: oW-WO 00 0 00 ° 0F'Jo
w aUm ¢Z co ZVW 22 Lo 0 _,
Z JJ Z Z Z a)0, Z
ce ~~ = =
U lii c U77 c CC c
Sco2 c (r)7—C7 c
Q 0 to 0) i/) 0)
Y Y Y Y Y
(n CO CO CO M
N N D D D
@ co co co co
J J J J _I
(f) \ in
d M a) O a 0 CO O O d a) M d il..F O O Q O M
cn co
(0 t0 (0 0 0 co co0
Y C s C s
E C `) C O 2 C D C a " `O � co ?)
M a co o o � a
aNUaN U U UW O W O U Wd m Warh, In
a 2 t 2 o 2 o o
F D i_ D F. N F a) F a)a) coa) o) J CO
Co JD oM K JO oM fY JU `,. Jr J `L"' ` co J0 r'• CC .
Ui Q C '- a s - Q a Q c J Q
I- Ili D a) WJ a) O) W-J '' O a WJ • .- 0 a WJ -' D O)
in < '7) < 'w < 'y Q 'w Q
- 0 0 0 0
CO-- Li-- 0
JY C.c. Y Y Y Y Y
C a C a C a C a C
W 0 v) 2 Cl) D U 2 N 2 U d
Z y ¢ a ¢ < ¢ < d
W 6 a a a a. a
U .� D , 0 • 0 d
0 C O N O co `- N N +� co
Z N in M V7 N M N N � N w # y '' N
O_ w o O N '.I' N Y .'1 N Y V N
Q 'C m O J m m m m
a_ a
U N o
H
NCL a
C NI- Q a_ N co I_ m co4 m N
( a) I- U N 19 H N
Q V t\ co M Mil J
W M CO M (O
�� W 03 N N CC r CO wwQ
w ^ ~ M a ¢ M L '- Y
Z o o Q oy o o >-
E
IL n. r f-) O O I- , w r in .D+ O
2 C W co as m C W co @ m) C p M CO m CO W M (Q CO R N (0 O
• J CO 0_0_ CO O.d O1 O-O. O O.D. CO O.D..
(� . . (0 x D D . . co x C) D . . (6 x O D . . co x Q) D .. N x a) D
Q 4t0w o a •*Uw o °- *Uw CO a stow o a •
*ow g a
F D D O L U D D L U D D L U D O D L U D D L U
f/) N N N fll N CO N y co N C) N N u)
J- C C C d c C C C a. co C C C O- CO C C C dCO CD
D D D N C C C C a. 0
Q a) a) a) N C CD CD CD N C D D D N C D a) D a c
U U O D 0 U U U )o o U o U D O U o U D 0 U U U D o
JJJ H 0 J J J ♦- 0 J 'CI J F 0 'CI IDJ H 0 JJJ 1" U
N N N N 0
N co co U1 N
N N 2 N d
U
(n e a 0 a `0 a 0 a _0 0
o 0 a, O y Oa) Oa,
Ce) C O C C C C O
0 22 < 2a 2a 2a >" 2a
CO OD DE OD OE c
H r !C- M IO- F W F
Wr. c
wm o COto o 0
2 co `o =a0 `o co `o o J U `o
W
f ea
I- Z>00 r 05 UU a' 0 0U Ca
o' O -U�a J J 0
Q a Q U W JJ w
2 MI-W o 0 LLI>W o WSW o ww o WW o
W W W Cr)QW :C' Y00Y 0 II
W 11)OW 5 OSW a Jm- a QQ
Lji enC`� c NC 2�r c 00 c Oa c
a < N(n CO CO
Renewa.
Child& Adult Care Food Program
CM' ^..,rr ro rinrapr.IANCE REVIEW
65103 05
FAMILY EDUCATION NETWORK
OF WELD COUNTY
PO BOX 1805
GREELEY, CO 80632-1805
The Colorado Department of Public Health and Environment, Child and Adult Care Food Program is required to conduct a preaward civil rights
compliance review of centers or sponsors of centers applying for CACFP participation. Please complete the following information below.
Renewing centersmay reuse information sent last year for question#1 only.
1. List the ,ioa •t for each raciaUethnic group in the community served by your center. Usually this information can be obtained from the jj
school •istnct. • ber of Commerce.Census Bureau.or Public Library. If you have more than one center,combine this information for all centers.
• 5 % American Indian or Alaskan Native 21 To Hispanic (a person of Mexican, Puerto Rican, Cuban, Central or
South American, or other Spanish culture or origin, regardless of
• 5 % Asian or Pacific Islander race)
1 % Black(not of Hispanic origin) 77 % White(not of Hispanic origin)
2. *Count the actual number of children enrolled in your center for each group listed below. Write the number in the space provided. If
you have more than one center, combine this information for all centers.
5 American Indian or Alaskan Native 650 Hispanic(a person of Mexican Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, regardless of race)
5 Asian or Pacific Islander 2 73 White(not of Hispanic origin)
9 Black(not of Hispanic origin)
*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, 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 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 determine their racial/ethnic background and keep this information in a confidential place.
3. Do you do any activities to assure that minority populations and grassroots organizations have an equal opportunity to participate or are
informed about changes in the Program? YesX No If yes, please check all that apply:
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
Other. Please explain:
The CACFP requires all advertising about the food program to contain a nondiscrimination statement. Do or will the items you checked
above include the following nondiscrimination statement?Yes X No
In the operation of the Child and Adult Care Food Program, no child will be discriminated against because of race, color, national origin,
sex,age, or disability. Any person who believes that 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 N
If yes, please explain
We assure the Colorado Department of Public Health and Environment, Child and Adult Care Food Program that all enrolled participants in
the Child and Adult Care Food Program at the center(s) described on the application forms pre served the same meals at no separate charee
regardless or race, color, national origin, age, sex, or disability, and there is no discrimination in the course ot the meal service.
/'
Signature ot AOrtimistrator or Authorized R. presentative bate
J Administrator
Signature of the CDPHE-CACFP Title Date
(CDPnE-CACFP ]:\RENEWALS\CNn.RGT.REN DM 6/97)
Renewal
•
Child&Adult Care Food Program
CIVIL urr_umc rnlUTDT TANeer 1UL'Vww
65103 05
FAMILY EDUCATION NETWORK
OF WELD COUNTY
PO BOX 1805
GREELEY,CO 80632-1805
The Colorado Department of Public Health and Environment, Child and Adult Care Food Program is required to conduct a preaward civil rights
compliance review of centers or sponsors of centers applying for CACFP participation. Please complete the following information below.
Reneawg centers may reuse information sent last year for question#1 only.
1. List the !...,r .t for each racial/ethnic group in the community served by your center. Usually this information can be obtained from the local
school •tstnct. . ber of Commerce.Census Bureau.or Public Library. If you have more than one center,combine this information for all centers.
•
. 5 % American Indian or Alaskan Native ;; % Hispanic(a person of Mexican, Puerto Rican, Cuban, Central or
• 5 - South American,or other Spanish culture or origin, regardless of
% Asian or Pacific Islander race)
1 % Black(not of Hispanic origin) 77 % White(not of Hispanic origin)
2. 'Count the actual number of children enrolled in your center for each group listed below. Write the number in the space provided. If
you have more than one center, combine this information for all centers.
5 American Indian or Alaskan Native 3 5 G Hispanic(a person of Mexican Puerto Rican, Cuban, Central or South
5 American,or other Spanish culture or origin, regardless of race)
Asian or Pacific Islander 273
73
9 Black(not of Hispanic origin) White(not of Hispanic origin)
*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, 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 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 determine their racial/ethnic background and keep this information in a confidential place.
3. Do you do any activities to assure that minority populations and grassroots organizations have an equal opportunity to participate or are
informed about changes in the Program? Yes No If yes,please check all that apply:
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
Other. Please explain:
The CACFP requires all advertising about the food program to contain a nondiscrimination statement. Do or will the items you checked
above include the following nondiscrimination statement?Yes x No_
In the operation of the Child and Adult Care Food Program, no child will be discriminated against because of race, color, national origin,
sex,age, or disability. Any person who believes that 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
We assure the Colorado Department of Public Health and Environment, Child and Adult Care Food Program that all enrolled participants in
the Child and Adult Care Food Program at the center(s)described on the application forms re served the same Teals at no separate charge
regardless or race, color, national origin, age, sex,or disability, and there is no discrimination in the course of the meal service.
Jc.r'_.tr1 /',— L i t--7�2_,LA-.e P
Signature of Administrator or Authorized Repr$ntatrve Date
Administrator
Signature of the CDPHE-CACFP Title Date
(CDPHE-CACFP I:RENEWALS\CIVQ.RGT.REN DM 6/97)
4,6,ym(vt; mEmoRAnDum
Weld County Board of
Elk To County Commissioners September 30, 1997
Date I
COLORADO From Walter J. Speckman, Executive Director,DHS
suejactChild Adult Care Food Program Agreement
Enclosed for Board approval is an Agreement between the Colorado Department of Health and Environment,
Child and Adult Care Food Program and the Family Educational Network of Weld County(FENWC), for
reimbursement to FENWC for meals served to children. This Agreement is an on-going Agreement.
If you have any questions, please telephone Tere Keller-Amaya at 353-3800, extension 3342.
972190
Hello