Home Health & Nutrition Services Child and Adult Care Food Program (CACFP) Provider Application Change Form Child and Adult Care Food Program (CACFP) Provider Application Change Form Instructions Complete only the applicable fields on this document to make changes to an existing approved application. If the provider is moving, changing approval types, requesting a name change or transferring, a full application is required with all required supporting documents. Sponsor Representative Organizational Details and Contact Information Name of Sponsoring Organization: - None -Fort Huachuca dba US Army Child, Youth, and School Services (022501000)Mid-State Child Care and Nutrition (042501000)Arizona Association of Family Day Care Providers (072508000)BJ Enterprises (072509000)Nutrition For Children (072512000)Nutrition And Health Education Resources (072513000)Luke AFB Family Child Care (072515000)Actively Building Child Care Inc. (072517000)Davis-Monthan AFB Child Development Programs (102241000)Child & Family Resources Inc. (102501000)Comite De Bienestar, Inc. (142503000) First Name Last Name E-mail Address Sponsor Representative Contact Informaiton Provider Information Provider’s Name: Provider’s Date of Birth (DOB) Physical Address: Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Country - None -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Section 1 – Provider Details Provider Details Has the Provider's Phone number or email address changed? Yes No Has the phone number changed? If yes, please enter new phone number. If no, leave blank. Has the Provider E-Mail address changed? If yes, please enter new E-Mail address. If no, leave blank. Backup Provider Details Backup Provider Name: FPC Expiration Date Is this a new Backup Provider? Yes No Please upload fingerprint card Upload One file only.100 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Is this to Delete a Backup Provider? Yes No Do you have another Backup Provider to update changes? Yes No I need to make updates to a second Backup Provider Backup Provider Name: FPC Expiration Date Is this a new Backup Provider? Yes No Please upload fingerprint card Upload One file only.100 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Is this to Delete a Backup Provider? Yes No Please complete this section if you need to add any new backup provider, update a backup provider's FPC Expiration Date or remove a backup provider. Note: For all new backup providers, please upload fingerprint card (FPC) or application. Please identify any changes being made to the initial application for any of the sections below. Section 2 - Provider Application Changes Do you need to update new hours of care (start time and/or end time)? Monday Tuesday Wednesday Thursday Friday Saturday Sunday Check the day of the week where Hours of Care have been changed (the start time or the end time). Monday New Hours of Care Start Time New Hours of Care - End Time Tuesday New Hours of Care Start Time New Hours of Care - End Time Wednesday New Hours of Care Start Time New Hours of Care - End Time Thursday New Hours of Care Start Time New Hours of Care - End Time Friday New Hours of Care Start Time New Hours of Care - End Time Saturday New Hours of Care Start Time New Hours of Care - End Time Sunday New Hours of Care Start Time New Hours of Care - End Time Explain variations in days or hours of care. Holiday Care Updated Information New Year’s Day Memorial Day July 4th Martin Luther King Jr. Day Columbus Day Labor Day Thanksgiving Day Christmas Presidents Day Veterans Day Other Check all that apply: If Other, which Holiday? Providers Own Children How many of Provider’s own children will be claimed: Section 3 – Meal Service Do you need to update new hours of meal service (start time, end time, and/or frequency)? Yes, I need to make a change to my hours and/or frequency of the 1st shift of meal service. Yes, I need to make a change to my hours and/or frequency of the 2nd shift of meal service. No, I have no changes to meal service hours or frequency. 1st Shift Breakfast New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" AM Snack New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" Lunch New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" PM Snack New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" Supper New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" Evening Snack New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" 2nd Shift Breakfast New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" AM Snack New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" Lunch New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" PM Snack New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" Supper New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" Evening Snack New Start Time New End Time How Often? Weekdays Weekends Holidays Other Please specify "Other" and/or which "Holiday" Attestation Sponsor Representative Signature I, the Sponsor Representative, hereby certify any of the above changes made to the initial application have been communicated by the provider to the sponsoring agency and have been approved effective on this date. Change request was received from provider by Email Phone Other If "Other", please specify how change request was received: Date Submit Leave this field blank