Virginia Cacfp Infant Feeding Preference / Parent Choice Form printable pdf download

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.

__________________________________________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

Birth – 3 months

4 – 7 months

8 – 11 months

in 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.

____________________________________________________

___________________________

Signature of Parent/Guardian

Date

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

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

3. 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.

4. If the parent/guardian declines the formula and the provider provides required meal and/or snack components, the

meal may be claimed for reimbursement.

5. 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, 2015

Virginia Cacfp Infant Feeding Preference / Parent Choice Form

Related Articles

Related forms

Related Categories