Nebraska Child and Adult Care Food Program Inquiry

Name of Center:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Sponsoring Organization (if applicable):

Phone(Required)

Contact Name(Required)

First Last

Child Care or Adult Care:

Child Care

Adult Care

Is the Center Licensed:(Required)

Licensed Capacity:

Program Eligibility:(Required)

# of Title XIX or XX

TOTAL ENROLLMENT:

PERCENTAGE:

Please enter a number from 0 to 100.

Number of sites(Required)

Does Center provide care to infants under one year of age:(Required)

Yes

Is food service:(Required)

Self-prepped

Vended (contract)

Comments and Follow-up

Thank you for submitting your information, someone will be contacting you to follow-up.