255 Capitol Street NE
Salem, OR 97310 / Office of Student Services
Child Nutrition Programs
(503) 947-5902
CHILD and ADULT CARE FOOD PROGRAM
PRELIMINARY APPLICATION
PROGRAM INFORMATION: The Child and Adult Care Food Program (CACFP) provides reimbursement for nutritious meals and snacks served to children in child care centers, family day care homes, schools, and to adults in adult care centers. The program is funded by the U.S. Department of Agriculture and administered by the Oregon Department of Education. Additional information is located at: http://www.ode.state.or.us/search/results/?id=209
INSTRUCTIONS: Complete each item. Submit completed and signed form and any required documentation to the address at the top of the form. Oregon Department of Education staff will review the application to determine if the organization meets the basic eligibility requirements, and notify you of your eligibility.
SECTION 1: ORGANIZATION INFORMATION
ORGANIZATION NAME______
MAILING ADDRESS______
CITY______STATE______ZIP CODE______COUNTY______
CONTACT NAME______TITLE______
CONTACT PHONE NUMBER______
CONTACT E-MAIL ADDRESS______
SECTION 2: ORGANIZATION STATUS – Check One
GOVERNMENT ORGANIZATION (public entity)
PRIVATE NON-PROFIT ORGANIZATION
Attach a copy of the IRS letter documenting the organization’s IRS 501 (c)(3) tax-exempt status.
FOR-PROFIT/PROPRIETARY ORGANIZATION
Names of all owners:______
______
Meet required 25% requirement of low-income participants.
25% of licensed capacity or total enrollment eligible for Free or Reduced Price meals or
25% of licensed capacity or total enrollment receives Employment Related Day Care (ERDC) or
Title XIX adult beneficiaries
TRIBE
RELIGIOUS ORGANIZATION
Attach a copy of the IRS letter documenting the organization’s IRS tax-exempt status, or a statement on church letterhead stating the care program is part of the church's mission.
SECTION 3: APPLICATION TYPE
CHILD CARE CENTER
AFTERSCHOOL MEALS AND SNACKS PROGRAM (AT-RISK)
BEFORE AND AFTER SCHOOL CARE PROGRAM
HEAD START
HOMELESS EMERGENCY SHELTER
ADULT DAY CARE
SECTION 4: CURRENT OPERATIONS
Ages of participants in care: From: ______To: ______
Check all that apply:
THE ORGANIZATION IS CURRENTLY PROVIDING SERVICES
______Number of participants currently participating
______Number of sites
THE ORGANIZATION HAS NOT BEGUN OPERATIONS
THE ORGANIZATION HAS AN AGREEMENT WITH THE OREGON DEPARTMENT OF EDUCATION CHILD NUTRITION PROGRAMS TO OPERATE THE NATIONAL SCHOOL LUNCH PROGRAM OR THE SUMMER FOOD SERVICE PROGRAM
Child Nutrition Programs Agreement Number:______
SECTION 5: FOOD SERVICE INFORMATION
Check one:
The organization has the ability and capacity to prepare and serve meals and/or snacks
The organization purchases or plans to purchase meals and/or snacks from another entity, and has the capacity to serve meals
The organization currently does not have the capacity to serve meals. If checked, explain how the organization plans to serve meals and/or snacks:______
______
SECTION 6: CHILD CARE CENTERS (skip if not applicable)
CHILD CARE CENTER REQUIRED TO BE CERTIFIED BY THE OREGON CHILD CARE DIVISION
Certificate #: ______Expiration date: ______
Ages approved: ______to______
Approved capacity: ______
SECTION 7: ALL ORGANIZATIONS EXEMPT FROM CHILD CARE CENTER LICENSING, INCLUDING ALL HOMELESS PROGRAMS, SOME AFTERSCHOOL MEALS & SNACKS PROGRAMS; HEAD STARTS, TRIBES, ADULT DAY CARE PROGRAMS (skip if not applicable)
Date of last satisfactory sanitation inspection Date: ______
Date of last satisfactory fire inspection Date: ______
Have not had sanitation or fire inspection but will pass inspections before program is approved
SECTION 8: HOMELESS PROGRAMS (skip if not applicable)
Check all that apply:
Participants eat all or some meals in group settings, such as family style meal service or cafeteria line.
The homeless shelter provides temporary residence to children age 18 and younger.
Note: The shelter may qualify if it provides services to children age 18 and younger and adults over age 18.
SECTION 9: AFTERSCHOOL MEALS AND SNACKS (AT-RISK) QUALIFICATION (skip if not applicable)
Check all that apply:
The organization has after school enrichment activities.
The organization's after school program is open to all.
NOTE: Athletic teams and scholastic clubs that limit membership do not qualify.
To qualify for the program, a site must be within the boundary of a low-income school area or have participated in the Summer Food Service Program (qualified by school data) the previous summer. Check this link to see if the site is within the boundary of a school on the list, and complete the information below. http://www.ode.state.or.us/wma/nutrition/cacfp/cacfp-public-regular-schools-greater-than-or-equal-to-50pct-eligibility_20140214.pdf
Site name: ______Name of qualifying school are: ______
Site name: ______Name of qualifying school area: ______
Site name: ______Name of qualifying school area: ______
Add additional pages if necessary
SECTION 10: DUNS NUMBER DUNS® (Data Universal Numerical System)
DUNS Number: ______
Will obtain a DUNS number before program is approved for CACFP participation
To obtain a DUNS number by phone:
Toll-free number 1.866.705.5711
If you have the required information, this process takes ten minutes with the DUNS® number being assigned at the conclusion of the call.
To obtain a DUNS number via the web:
Link: http://fedgov.dnb.com/webform This process takes about 30 days to obtain the DUNS® number.
CERTIFICATION
I certify that the information in this application is true and correct. I certify that during the past seven years, neither the institution nor any of its principals have been declared ineligible to participate in any other publicly funded program by reason of violating that program's requirement. I understand that institutions and individuals providing false information will be placed on the National disqualified list and will be subject to civil or criminal penalties. I certify that if the organization participates on the Child and Adult Care Food Program it will abide by all applicable state and federal regulations and policies. I understand this is a preliminary application and if accepted, I will be required to attend training and submit additional required information to complete the Child and Adult Care Food Program application process.
______
Signature of Organization Representative Date
(Must be organization principal and have authority to enter into legal agreements and contracts)
______
Printed name of Organization Representative
PRELIMINARY APPLICATION SUBMISSION CHECKLIST – Check all enclosed documents
Non-Profit Programs:
IRS 501 (c)(3) Tax-Exempt Status letter with current address
Religious Organizations:
Letter stating affiliation with religious organization
EMAIL, FAX, OR MAIL APPLICATION AND SUPPORTING DOCUMENTS TO:
Email:
Fax: (503) 378-5156 Attn: Shannon Smith
Mail: Shannon Smith
Child Nutrition Programs
Oregon Department of Education
255 Capitol Street NE
Salem, OR 97310
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:
This institution is an equal opportunity provider.
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Preliminary Application (Center)