Center Enrollment/Eligibility Roster - Child and Adult Care …



OREGON DEPARTMENT OF EDUCATION Page 1 of      

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

CACFP CHILD ENROLLMENT ROSTER

(Child Care Centers, Head Start Programs, Outside School Hours Sites)

Instructions:

1. Complete and save this form for each CACFP site every October. Enter the Sponsor name, Site name, the month and year. To request a new OMER for a later month (in addition to October), contact your assigned Specialist (For-Profit centers see note below).

2. CIS/CEF #: This number will be used to connect Confidential Income Statements (CIS) and CACFP Child Enrollment Forms (CEF) to each participant name. Assign a number to each participant. When multiple participants are listed on a CIS and/or CEF, assign the same “CIS/CEF #” number on this roster to each participant listed on the CIS/CEF.

3. Participant Name: Participants listed must have current CACFP Child Enrollment Forms (CEF) on file for the OMER month. Number the CEF in the upper right corner, using the assigned “CIS/CEF #” on the roster. Outside School Hours Centers (OSHC) will use Sponsor’s own enrollment documents to determine participants to be listed.

4. Eligibility Determination: Check the box for the approved eligibility category from the most recent Confidential Income Statement (CIS). Number the CIS in the upper right corner, using the assigned “CIS/CEF #” on the roster. (CIS must be approved by the sponsor official no later than the last day of the OMER month.)

5. Current CACFP Enrollment Date: Enter the parent/guardian signature date from the most recent CEF. OSHC do not complete.

6. Transfer or Drop Date: Enter the date that the participant left the site or program.

|AGENCY/SPONSOR NAME |CNPweb SITE NAME |MONTH |YEAR |

|      |      |      |      |

|OMER |Free |      |Reduced Price |      |Above Scale |      | |

|(One | | | | | | | |

|Month | | | | | | | |

|Enroll| | | | | | | |

|ment | | | | | | | |

|Report| | | | | | | |

|) | | | | | | | |

|Totals| | | | | | | |

|for | | | | | | | |

|all | | | | | | | |

|pages | | | | | | | |

|to be | | | | | | | |

|entere| | | | | | | |

|d on | | | | | | | |

|CNPweb| | | | | | | |

|Site | | | | | | | |

|Claim | | | | | | | |

| | | |F |RP |

|For-Profit sites: Keep this form current for each month of the fiscal year; starting with the month prior to CACFP approval, or October, whichever is latest. At a |

|minimum 25 percent of the enrolled participants or licensed capacity, whichever is less, must be eligible for free and reduced price meal reimbursement according to the |

|USDA’s household size and income guidelines; OR, that a minimum 25 percent of the enrolled participants or licensed capacity, whichever is less, must be receiving State |

|and/or Federally subsidized care (Title XX). If using Title XX to determine if the site is eligible: Record the Title XX (State pay) remittance notice date for the |

|claim month. |

| |

|I hereby certify that all of the above enrollment and eligibility information for current participants is true and correct and that records are available to support this|

|document. |

|NAME AND SIGNATURE OF SPONSOR REPRESENTATIVE |DATE |

|      |      |

OREGON DEPARTMENT OF EDUCATION Page 2 of      

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

ONE MONTH ENROLLMENT ROSTER (OMER)

(Child Care Centers, Head Start Programs, Outside School Hours Centers)

|Roster|CIS/CEF # |PARTICIPANT NAME |ELIGIBILITY |CIS SPONSOR |CURRENT CACFP |FOR-PROFIT SITES |TRANSFER |

|# | |Last name, First name |DETERMINATION |OFFICAL |ENROLLMENT FORM|ONLY: SUBSIDIZED |OR |

| | | | |DETERMINATION |DATE |CARE (TITLE XX) PMT|DROP DATE |

| | | | |Date | |DATE | |

| | | |F |

|Totals from page 1 |      |      |      |

|TOTAL all pages |      |      |      |

|If Last Page of Roster enter in OMER block on page 1 | | | |

OREGON DEPARTMENT OF EDUCATION Page 3 of      

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

ONE MONTH ENROLLMENT ROSTER (OMER)

(Child Care Centers, Head Start Programs, Outside School Hours Centers)

|Roster|CIS/CEF # |PARTICIPANT NAME |ELIGIBILITY |CIS SPONSOR |CURRENT CACFP |FOR-PROFIT SITES |TRANSFER |

|# | |Last name, First name |DETERMINATION |OFFICAL |ENROLLMENT FORM|ONLY: SUBSIDIZED |OR |

| | | | |DETERMINATION |DATE |CARE (TITLE XX) PMT|DROP DATE |

| | | | |Date | |DATE | |

| | | |F |

|Totals from Page 2 |      |      |      |

|TOTAL all pages |      |      |      |

|If Last Page of Roster enter in OMER block on page 1 | | | |

OREGON DEPARTMENT OF EDUCATION Page 4 of      

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

ONE MONTH ENROLLMENT ROSTER (OMER)

(Child Care Centers, Head Start Programs, Outside School Hours Centers)

|Roster|CIS/CEF # |PARTICIPANT NAME |ELIGIBILITY |CIS SPONSOR |CURRENT CACFP |FOR-PROFIT SITES |TRANSFER |

|# | |Last name, First name |DETERMINATION |OFFICAL |ENROLLMENT FORM|ONLY: SUBSIDIZED |OR |

| | | | |DETERMINATION |DATE |CARE (TITLE XX) PMT|DROP DATE |

| | | | |Date | |DATE | |

| | | |F |

|Totals from page 3 |      |      |      |

|TOTAL all pages |      |      |      |

|If Last Page of Roster enter in OMER block on page 1 | | | |

OREGON DEPARTMENT OF EDUCATION Page 5 of      

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

ONE MONTH ENROLLMENT ROSTER (OMER)

(Child Care Centers, Head Start Programs, Outside School Hours Centers)

|Roster|CIS/CEF # |PARTICIPANT NAME |ELIGIBILITY |CIS SPONSOR |CURRENT CACFP |FOR-PROFIT SITES |TRANSFER |

|# | |Last name, First name |DETERMINATION |OFFICAL |ENROLLMENT FORM|ONLY: SUBSIDIZED |OR |

| | | | |DETERMINATION |DATE |CARE (TITLE XX) PMT|DROP DATE |

| | | | |Date | |DATE | |

| | | |F |

|Totals from page 4 |      |      |      |

|TOTAL all pages |      |      |      |

|If Last Page of Roster enter in OMER block on page 1 | | | |

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