DCH 16 (Rev. 2/2022) Permanent Agreement Between a Sponsor and a Day Care Home Provider - Sponsor Representative - Xiuling Goble - and - Day Care Home Provider
This Agreement is entered into on , by and between CocoKids, Inc. of 1035 Detroit Avenue, Suite 200, Concord, CA 94518 and , Date of birth of .
This Agreement specifies the responsibilities of the sponsor and day care home provider (hereinafter referred to as “provider”) as participants in the U.S. Department of Agriculture’s (USDA) Child and Adult Care Food Program (CACFP).
The sponsor may add information to the following Agreement. However, in no case shall such changes limit children’s and/or infants’ access to the CACFP or change any USDA or California Department of Social Services (CDSS) requirements, regulations, or policies.
In accordance with Title 7, Code of Federal Regulations (7 CFR), Section 226.18(b):
The Sponsor Agrees to:
The Provider Agrees to:
The provider and employees of the provider understand that this is a federal program and that they are responsible for information provided to the sponsor. Falsification or misrepresentation of information on any document may lead to termination from the CACFP, and/or criminal penalties, and/or civil penalties. Any funds found to be misappropriated by providers must be returned to the sponsor by the provider.
Both the Sponsor and Provider Agree to:
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;Fax: (202) 690-7442; orEmail: [email protected]This institution is an equal opportunity provider.
CertificationWe agree to comply with the rights and responsibilities in this Agreement for participation in the U.S. Department of Agriculture, Child and Adult Care Food Program, in California.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: DCH 16 (Rev. 2/2022) Permanent Agreement Between a Sponsor and a Day Care Home Provider - Sponsor Representative - Xiuling Goble - and - Day Care Home Provider
Agree & Sign