Virginia Cacfp Meal Benefit Income Eligibility Form For Child Care Centers And Family Day Homes (Page 3 of 3) in pdf

VIRGINIA CACFP INFANT FEEDING PREFERENCE / PARENT CHOICE FORM

Name of Infant

Date of Birth

(first/last name)

(month/day/year)

This center participates in the Child and Adult Care Food Program (CACFP) and receives USDA reimbursement for serving nutritious meals to infants

and children. Participation in this program requires caregivers to follow specific meal patterns according to the age of the child being fed.

Joyful-Care Children's Center, LLC

will feed your infant breast milk provided by you and/or we will

(name of center)

provide iron fortified infant formula. The formula we provide is:

Policy requires a center participating in the CACFP to offer iron fortified formula to infants who are in care during meal service times .

Parents/guardians, however, may decline what is offered, and supply the infant’s formula.

Please mark your preference

Today’s Date _______________

(choose all that apply by initialing in

Birth - 3 months

4 - 7 months

8 - 11 months

the appropriate space)

I will bring expressed breast

milk for my infant.

I will come to the center to

breastfeed my infant.

I want the center to provide

formula for my infant

I will bring formula for my infant.

The formula is:

In order to claim meals for reimbursement, the center must provide iron fortified infant cereal and other foods when your baby is developmentally ready for them.

Please mark your preference

Today’s Date _______________

4 - 7 months

8 - 11 months

I want the center to provide infant cereal and other foods for my

infant based on CACFP guidelines.

I will bring solid foods for my infant when s/he is ready for it.

Date

Signature of Parent/Guardian

This form must be kept on file for each infant enrolled for child care.

As situations change, such as a medical authority changing the infant’s formula , a new form should be completed.

This form must be kept current and accurate for each infant enrolled for child care until the infant reaches one year of age or is no longer on infant

formula.

If the parent/guardian declines the formula and the provider provides required meal and/or snack components, the meal may be claimed for

reimbursement.

If the parent/guardian declines infant meals/snack, meals and snacks may NOT be claimed for reimbursement .

Virginia Department of Health

Division of Community Nutrition

Revised July 1, 2014