INFANT FEEDING STATEMENT INFANT FEEDING SCHEDULE AND AGREEMENTProvider Name Name of Infant Date of Birth MM slash DD slash YYYY 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.Fill in name of formula here 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. Fill in name of formula here FORMULA (CHECK ONE) The provider can prepare and supply infant formula for my child. I will provide breast milk or formula for my infant. If necessary, provider can prepare the formula. FOOD (CHECK ONE) The provider can supply my infant with solid foods when I deem it appropriate I will bring solid foods for my infant I want my infant child to be fed according to the following schedule (please check one): On Demand As requested Schedule 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 SignatureDate MM slash DD slash YYYY Provider’s SignatureDate MM slash DD slash YYYY Developed by Child Development Council Last Revised 5/2009
