• Child and Adult Care Food Program (CACFP)

    Adult Participant Enrollment/Information Form
  • This facility is involved in the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP). CACFP needs proof of enrollment for all participants. Please complete the following information. Be sure to sign and date in the space provided. Thank you.

    This information can be provided by the participant or an adult household member.
  • 7 CFR §226.2 defines “functionally impaired adult” as “chronically impaired disable persons 18 years of age or older, including victims of Alzheimer’s disease and related disorders with neurological and organic brain dysfunction, who are physically or mentally impaired to the extent that their capacity for independence and their ability to carry out activities of daily living is markedly limited. Activities of daily living include, but are not limited to, adaptive activities such as cleaning, shopping, cooking, taking public transportation, maintaining a residence, caring appropriately for one’s grooming or hygiene, using telephones and directories, or using a post office. Marked limitations refer to the severity of impairment, and not the number of limited activities, and occur when the degree of limitations is such as to seriously interfere with the ability to function independently.”
  • 7 CFR §226.2 defines “group living arrangement” as “residential communities which may or may not be subsidized by federal, State or local funds but which are private residences housing an individual or a group of individuals who are primarily responsible for their own care and who maintain a presence in the community but who may receive on-site monitoring.”
  • Participant/Adult Household

  • MM slash DD slash YYYY
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