Request for a Certificate of Appreciation



Family Day Care Home Request for a Certificate of Appreciation

From Department of Public Instruction – Community Nutrition Team

Do you know of a Child Care Provider who has reached a milestone for years of participation in Child and Adult Care Food Program? The Department of Public Instruction – Community Nutrition Team would like to recognize him/her for their many years of dedication and commitment to the health and nutritional well-being of the children they serve. Please complete and submit this form for a certificate of appreciation 30 days prior to the date the certificate is needed.

|Name of Child Care Provider or Sponsor Staff | |

|Print name clearly and exactly as it is requested on certificate. | |

|Include credentials, if applicable, and requested on certificate. | |

|Total Years of Participation in the CACFP | |

|Sponsoring Organization | |

|List current Sponsoring Organization of the Provider. | |

|Sponsor Official’s Name and Title | |

|Print name and title clearly and exactly as it is requested on | |

|certificate. Include credentials, if applicable, and requested on | |

|certificate. | |

|Date to be Printed on Certificate | |

|Name of Person Requesting Certificate | |

|Send Certificate to Address | |

| | |

| | |

Email or fax completed request form to: Email: cnt@dpi.

Operations Program Associate

DPI – Community Nutrition Team

Fax #: 608-267-0363

For DPI Use

|Date request received | |

|Date certificate mailed to Sponsor | |

OPA to scan and save completed form on G drive Shared\FNS\CACFP\FDCHs\Certificate of Appreciation

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download