INFANT FEEDING STATEMENT
INFANT FEEDING SCHEDULE AND AGREEMENT
Provider Name____________________________________________
Name of Infant____________________________________________ Date of Birth_________________
DEAR PARENT/GUARDIAN
□ (Non CACFP participant) I will give your baby____________________ (name of Formula) and solid food. If you prefer, you can supply your own formula or food. Please let me know your choice by checking below.
□ I participate in the Child and Adult Care Food Program and will give your baby __________________
(name of Formula) and solid food. If you prefer, you can supply your own formula or food. Please let me know your choice by checking below.
|FORMULA (CHECK ONE) |FOOD (CHECK ONE) |
| | |
|______ The provider can prepare and supply |______ The provider can supply my |
|infant formula for my child. |infant with solid foods when I |
| |deem it appropriate. |
| | |
|_______ I will provide breast milk or formula |______ I will bring solid foods for my |
|for my infant. If necessary, provider |infant. |
|can prepare the formula. | |
| | |
I want my infant child to be fed according to the following schedule (please check one):
□ On Demand
□ As requested _______________________________________________
_______________________________________________
Signatures on this document imply that both parties understand:
✓ Children 6 months of age and under must be held during all bottle feedings (417.12(m)).
✓ Microwave heating of infant food and formula is prohibited by regulation (417.12(k)(2)).
✓ The Child Care Provider must make every effort to accommodate the needs of a child who is breast-fed
(417.12(l)).
Parent’s Name_________________________________________
Parent’s Signature ______________________________________ Date______________
Provider’s Signature_____________________________________ Date______________
................
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