/ Child & Adult Care Food Program
Child Care Centers
At-Risk Afterschool Meals Addendum
Renewal FY 2013 /

Child Nutrition Programs

Teaching and Learning Support

801 West 10th Street, Suite 200
P.O. Box 110500
Juneau, Alaska 99811-0500
Phone (907) 465-8711
Fax (907) 465-8911

Sponsoring Agency Name:______

School District ______Yes _____ No

1. Is each site’s food service operated principally for the benefit of the students attending the Afterschool Program? ______YES ______NO

2.  Educational/Enrichment Activities offered at the afterschool program

The purpose of the after school program(s) is to provide care. ______YES ______NO

Each site will include an educational or enrichment component and be organized to provide children/students with regularly scheduled activities that are structured and organized.

______YES ______NO

Describe the activities being offered by your program. If the activities vary at each site, please list each site separately. Submit documentation of scheduled activities.

3.  Procedure for recording and collecting records from each site (required records include a daily roster of children attending the site, the number of snacks served each day, menu records, and records of quantity of food prepared/received from vendor.)

A) How will you record daily attendance? Who will record?

B)  How will you record the number of snacks and or meals served to students each day? Who will record?

C)  Who will plan cycle menus and document the quantities served?

D)  Where will these records be maintained on file?

E)  Who will complete the CACFP Claim for Reimbursement?

4.  Will you be offering At-Risk Afterschool Snacks? ______YES ______NO

List sites that will have snacks:

5.  Will you be offering At-Risk Afterschool Supper? ______YES ______NO

List sites that will have suppers and if they are prepared on site or purchased by an approved vendor:

6.  Will you be offering At-Risk Snacks or Meals on weekends and or holidays during the school year?

______YES ______NO

All Self-Prep sites must have Department of Environmental Conservation (DEC) or Municipality of Anchorage (Muni) approved kitchen, with a Certified Food Protection Manager (CFPM) on staff.

ATTACH BACK-UP DEC/MUNI HEALTH & SANITATION DOCUMENTATION OF AN APPROVED KITCHEN (not applicable for school districts with approved kitchens).

______Health & Sanitation Documentation Attached

______Name of person with CFPM certificate

______(Sponsoring Agency) and each participating site agree to comply with all federal regulations and policies regarding participation in the After School At-Risk Meals Program. The following CACFP sites meet the requirements of the After School At-Risk Meals Program. *ATTACH BACK-UP NSLP FREE/REDUCED & SCHOOL DISTRICT BOUNDARIES DATA (not applicable for school districts with program in school).

Name of At-Risk Site / Name of Nearest Public School / % of
Free/
Reduced / Year of % Free/Reduced Data / First Day of School / Last Day of School

The sponsor agrees to:

·  Operate the At-Risk Afterschool Meals Component in compliance applicable with State and/or local health and safety standards.

·  Operate the At-Risk Afterschool Meals Component, accepting final administrative and managerial responsibility for operations and to meet all Program requirements.

·  Claim reimbursement for at-risk afterschool meals only, however, snacks & meals may be claimed on weekends and holidays during the school year. At-Risk Afterschool Meals shall not be reimbursed in programs operated before or during the child’s school day or during the summer vacation. Other meals served to qualifying children may be claimed at the regular rate percentage approved by the Department and the required family size and income information is collected through the Confidential Income Statement.

·  Provide snacks and/or meals to all students at no charge.

·  Only claim for reimbursement those snacks and/or meals that meet or exceed the minimum standards established for meal supplements, and to maintain documentation of the foods and portions served to meet these standards.

·  Maintain a roster or sign in sheet at each site to verify daily attendance, and to implement a system to document the service of snack and/or meals to each child. To claim no more than one snack and one meal per child per day.

·  Maintain adequate documentation of program expenditures to insure a non-profit food service operation.

·  Self-monitor each site (school districts 2 x/year and other programs 3 x/year).

·  Coordinate with other organizations and school districts and submit required agreements to the state agency.

______

Authorized Signing Authority (Sponsor) Date

State Agency Approval______

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Rev. 6.12