BRIGHT FROM THE START
|BRIGHT FROM THE START |
|GEORGIA DEPARTMENT OF EARLY CARE AND LEARNING |
|CHILD AND ADULT CARE FOOD PROGRAM |
| |
|DAY CARE HOME PRE-OPERATIONAL VISIT FORM |
|I Personal | |
| |Date of Birth __________________ |
|Provider’s Name ______________________________________________________________ | |
| |Social Security Number _________________ |
| | |
|Address _______________________________________________________ |Telephone Number ____________________ |
| | |
|City _________________ State_____________ Zip ________ County____________ |Email ________________________________ |
|Certificate of Registration/License Number _________________________________________ |License Capacity ______________________ |
| | |
|Effective Dates of Registration/ License____________________ |Number of Children Enrolled _____________ |
| | |
|( Family Day Care Home ( Group Day Care Home |Number of Provider’s Own Children _______ |
| | |
| |Number of Additional Children _________ |
| |(Must be approved by Childcare Licensing) |
| | |
|Days of Operation ________________________________ |Hours of Care _____________________________________________ |
| | |
| |Shift Care Provided? ( Y ( N |
|II Eligibility and Meal Service |Tier Category Determined by: |
| | |
|Tier Category: |( School Zone ____________________________________________ |
| |( Name of School/County) |
|( Tier I ( Tier II High (Tier II Low ( Tier II Mixed | |
| |( Census Data ( Provider Eligibility ( IES forms |
| | |
|Approved Meal Types: ( B ( AM SNK ( L |Approved Meal Times: ____ B ____ AM SNK ____L |
| | |
|( PM SNK ( Supper |___PM SNK ____Supper |
|Meal Service Environment |Explain the following record keeping requirements |
| | |
|Are facilities adequate to provide a quality meal service to children? | |
|( Y ( N | |
| | |
|Is space available and sufficient to store required quantities of food? ( Y| |
|( N | |
| | |
| | |
| |____ Program Eligibility |_____ Tier Classification |
| | | |
| |____ Creditable Meals/ Food Crediting Guide |_____Reimbursement Rates |
| | | |
| |____Menus/Meal and Attendance Forms |_____Claim Calculation |
| | | |
| |____ Enrollment and Roster Forms |_____ WIC |
| | | |
Effective Date of Approval:_______________________ Date to begin claiming meals: _________________________
Month of First Review ___________________
_____________________________________________ ________________________________________
Signature of Sponsoring Organization Official Date
______________________________________________ _______________________________________
Signature of Day Care Home Provider Date
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