Child and Adult Care Food Program Eligibility Assessment

Before applying for the Child and Adult Care Food Program (CACFP), organizations must meet basic eligibility requirements. The CACFP Eligibility Assessment will be used to determine if your organization is eligible to apply for CACFP participation.

Eligible organizations must currently be offering care services and operating as a business for at least six months to meet ODE CNP financial viability requirements for operating the CACFP. Owners, operators, and/or the business cannot currently be on the USDA CACFP National Disqualified List (NDL). Additionally, if the organization is a child care center, it must be licensed by The Department of Early Learning and Care (DELC). If the organization does not meet this criterion, the organization is not eligible to apply for the CACFP.

Eligibility Assessment Instructions: Please complete the following eligibility questions. Once complete, you will be contacted via email by the Oregon Department of Education Child Nutrition Programs (ODE CNP) regarding your organization's eligibility and, if eligible, the next steps in the application process. Please note that the application process can be lengthy.

Note: This Eligibility Assessment is NOT for Family Daycare Home (FDCH) Providers. Only Family Daycare Home (FDCH) Sponsors should complete this form. If you are a FDCH provider who would like to participate in the USDA Food Program, please send an email to ODE.CommunityNutrition@ode.oregon.gov and we will send you instructions.

Organization Information

What is the legal name of the organization or company applying for CACFP sponsorship? This name should be consistent on registrations, licenses and financial information.*

If your organization does business under another name, list it here:*

If your organization is affliated with any other businesses, please list them here:*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Please provide website/webpage for your organization:*

What is the name of the person completing the assessment (contact person)?*

List the contact person's date of birth:*

What is the contact person's role within the organization?*

What is the contact person's email?*

What is the contact person's phone number?*

How did you hear about the Child and Adult Care Food Program?*

Have you or someone at your organization spoken with anyone at the Oregon Department of Education Child Nutrition Programs about the CACFP and/or the application process?*

Select

If yes, who did you speak to?

Organization Type

Select the program type(s) that your organization is applying to add CACFP to (check all that apply):

Family Daycare Home Provider

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STOP! If you are a Family Daycare Home Provider, this application is not for you!

This application is for the organization types listed below. Family Daycare Home Providers participate on the USDA Food Program under a Sponsoring Organization. If you are a provider, please send an email to ODE.CommunityNutrition@ode.state.or.us and we will send you the contact information for the organization in your area. Please do not submit this application if you are a licensed Family Daycare Home Provider (CF or RF license types).

Family Daycare Home Sponsor

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Sponsor of Unaffiliated Centers

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Child Care Center

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At-Risk Afterschool Meals and Snacks Program

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Is your site in an eligible school area?

An eligible school area means that the site you intend to serve meals at is within a school's attendance boundary where at least 50% of students are eligible for Free/ Reduced Price meals.

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List the school name:

Describe the enrichment programming offered at your site:

Adult Day Care Center

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Does the center provide a structured comprehensive program that provides a variety of health, social and related support services to enrolled participants in a group setting outside their home or group living arrangement on a less than 24-hour basis for functionally impaired adults with an individualized plan of care on file and/ or persons 60 years of age or older?

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Outside School Hours Care Center

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Head Start

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Do you offer community slots?

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Residential homeless shelter

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Is the primary purpose of the emergency shelter to provide temporary residential and food services to homeless children (defined as age 18 or younger) and/or their families?

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Organization Type and Status

Select "yes" for your organization type:

Government or Public Entity

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School District

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Non-Profit Organization - Attach a copy of the IRS letter documenting the 501(3)(c) status.

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Tax ID Number

For-Profit Organization - 25% of licensed capacity or total enrollment must be eligible for Free or Reduced Price meals.

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Does your organization meet the 25% requirement of low-income participants?

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List all owners:

Registration Status*

Is your organization registered with the Oregon Secretary of State?

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Tribe

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Religious Organization - Attach a copy of the IRS letter documenting the 501(3)(c) status or a statement on church letterhead stating the care program is part of the church's mission

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Does your organization operate in any states other than Oregon?*

Does your organization have a Unique Entity Identifier (UEI)?*

Select

If you do have a UEI, please provide this below.

File Attachments

*Non-Profits and Religious Organizations: Please attach required documentation here.

Drag and drop files here or

Operations

Is your organization currently providing care services?*

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If no, please describe your plan for opening:

Include your anticipated start date.

How long has your center/program been open?*

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How long has your center/program been licensed or approved to operate?*

Number of currently enrolled participants:*

Age range of participants:*

Number of sites:*

How is your site(s) eligible?*

*In order to be eligible, a site must either be CCLD licensed or have alternate approval (if not a child care center).

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If CCLD licensed, please list license number:

If you’re a non-profit/for-profit organization, is your organization currently registered with the Oregon Secretary of State Business Registry?

Select

Food Service

Does your organization have the ability to purchase or to prepare and serve meals and/or snacks?*

This is a program requirement.

Select

What meals do you plan to serve on CACFP?*

Select

What meals do you currently serve?

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Are meals prepared by the organization on-site (self-prep) or are they prepared and purchased from another food service company (vended)?

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Are families charged a fee separate from tuition for meals that are provided by the organization?*

Select

Federal Program Participation

Have you, or your organization ever been disqualified from participation in any other publicly funded program?*

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Disqualified from the following programs:

Are you, the organization, or any of its principals on the USDA CACFP National Disqualified List?*

Select

Names of disqualified person/organization:

Have you, or any of your organization’s board members or principals been convicted for fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or obstruction of justice during the past seven years?*

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Do you or your organization currently participant in any other Child Nutrition Program in Oregon?*

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If yes, please list the other programs here:

Do you or your organization currently participate in the USDA CACFP or other Child Nutrition Programs another state?*

Select

If yes, please provide the state and/or program that your organization participated.

Have you or your organization participated in the past in the USDA CACFP in the State of Oregon?*

Select

If yes, which programs?

USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1) mail:

U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410; or

2) fax:

(833) 256-1665 or (202) 690-7442; or

3) email:

Program.Intake@usda.gov

This institution is an equal opportunity provider.

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