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
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