missouri department of health and senior services
section for child care regulation
parent’s specialized instructions for infants and toddlers
date of birth
instructions to parents
• please complete for child who is less than 24 months of age.
• update diet information as needed until child is on complete table food. use a new form or initial/date changes on this form.
checK all that apply
holds own bottle
feeding table or chair
tYpe of food
Kinds of food
aMount of food
formula or breastmilK
arrangeMents for sleep – licensing rules require that infants be placed in a crib, on their back, to sleep.
time child usually naps
usual length of nap
special needs/instructions related to sleeping
my child is 12 months or older, and i give my permission for my child to sleep on a cot.
list any lotions and/or ointments, etc. that you have provided and give permission for caregivers to use on your child
i do not want caregivers to use any lotions, powders, ointments or similar items on my child.
i will furnish the following baby supplies for my child; clearly labeled with my child’s name
special instructions for care (restrictions, allergies, etc.)
parent/legal guardian signature
mo 580-1918 (3-13)