[text_content "Provider's Name: Little Peoples Childcare LLC"]

    [text_content "Address: 542 Naulton Road"]

    [text_content "Curwensville PA 16833"]

    [text_content "Agreement # 357-17-832-9"]

    [text_content "Pennsylvania Home-Based Child Care Providers Association, Inc."]

    [text_content "P.o. Box 1407 Clearfield PA, 16830 (814) 765-3471"]

    [text_content "Pahomeb65@gmail.com"]

    [heading "Child & Adult Care Food Program"]

    [text_content "Parents this institution participates in the.Child & Adult Care Food Program (CACFP) and receives reimbursement to provide more nutritious meals for your child(ren). Federal CACFP regulations require all parents and guardians to complete a CACFP Annual Enrollment Form when enrolling their child(ren) and again every year thereafter. This information will help ensure all children receive appropriate meals during their care."]

    * Your Name

    *Email

    *Phone Number

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    * Enrollment Date

    * Childs Name

    * Childs Address

    * Childs Town

    * Childs State

    * Childs Zip

    * Childs Birthdate

    * Childs Age

    * Parent Guardian Name

    * Parent Guardian Address

    * Parent Guardian Town

    * Parent Guardian State

    * Parent Guardian Zip

    * Parent Guardian Work Number

    * Parent Guardian Home Number

    * Is child related to provider

    * If yes, relationship

    * Regular Hours of Care "Full Time M-F" "Part-Time" "Drop-Ins"

    [heading "Monday"]

    Arrival (5:30am start)

    Depart (9pm end)

    [heading "Tuesday"]

    Arrival (5:30am start)

    Depart (9pm end)

    [heading "Wednesday"]

    Arrival (5:30am start)

    Depart (9pm end)

    [heading "Thursday"]

    Arrival (5:30am start)

    Depart (9pm end)

    [heading "Friday"]

    Arrival (5:30am start)

    Depart (9pm end)

    [heading "Saturday"]

    Arrival (5:30am start)

    Depart (9pm end)

    [heading "Sunday"]

    Arrival (5:30am start)

    Depart (9pm end)

    [text_content "Which meals will be served on a regular basis? (Please check all that apply)"]

    * Breakfast

    * AM Snack

    * Lunch

    * PM Snack

    *Supper

    * EVE Snack

    * Childs Ethnic Identity

    * Parent/Guardian Signature

    Your browser doesn't support signing

    * Today's Date

    [text_content "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."]

    [text_content "Persons with disabilities who require alternative mean 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."]

    [text_content "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:"]

    [text_content "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:"]

    [text_content "(1) Mail: U.S. Department of Agriculture"]

    [text_content " Office of the Assistant Secretary for Civil Rights"]

    [text_content " 1400 Independence Avenue, SW"]

    [text_content " Washington, D.C. 20250-9410;"]

    [text_content "(2) Fax: (202) 690-7442; or"]

    [text_content "(3) Email: program.intake@usda.gov. This institution is an equal opportunity provider."]