Hcnp.hawaii.gov



|State of Hawaii |ATTENDANCE AND ELIGIBILITY ROSTER |

|Department of Education |CHILD AND ADULT CARE FOOD PROGRAM |

|Hawaii Child Nutrition Programs |FEDERAL FISCAL YEAR 2021 (RETAIN THIS FORM FOR REVIEW BY HCNP) |

|650 Iwilei Road Suite 270 | |

|Honolulu, Hawaii 96817 | |

|NAME OF FACILITY: |AGREEMENT NUMBER: |

| |DATE ENTERED INTO | |CATEGORY OF ELIGIBILITY | | |

| |PROGRAM |DATE EXITED FROM | |DATE MBF SIGNED BY |DATE AND INITIALS OF |

| |FFY 2021 |PROGRAM | |HOUSEHOLDMEMBER |DETERMINING OFFICIAL |

|NAME OF CHILD/PARTICIPANT | | | | | |

| | | |F |RP |AS | | |

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