Adult Care Food Program (ACFP) – Rae's Playze Adult Day Center

Child and Adult Care Food Program (CACFP)

Adult Participant Enrollment/Information Form

Institution Name:

Agreement Number:

Facility Name:

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.

Participant’s Name:*

Participant’s Age:*

Is the adult participant 60 years of age or older?*

Yes
No

Is the adult participant a “functionally impaired adult”?*

Yes
No

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.”

Does the adult participant reside in his/her own home? Resides in own home:*

Yes
No

If the adult participant does not reside in his/her own home, does the adult participant reside in a “group living arrangement”? Group living arrangement:*

Yes
No

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.”

If the adult participant does not reside in his/her own home or in a “group living arrangement” please describe the type of residence:*

Participant/Adult Household

Member Signature:*

Date*

Printed Name of Person Signing Above:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Telephone Number:*

Work Telephone Number:*