Provision Of Infant Formula Form printable pdf download

CHILD AND ADULT CARE FOOD PROGRAM

PROVISION OF BREASTMILK OR

INFANT FORMULA AND PROVISION OF BABY FOOD

Name of child care provider or center

This institution/facility offers_______________________________ formula for infants

(Iron-Fortified Formula name must be filled in by institution/facility)

through the Child and Adult Care Food Program. It is a parental choice whether or not

to use this formula based on you and your infant’s needs.*

Please select from (√) the following choice(s):

_____ I will provide breastmilk for my infant.

_____ I will use the iron-fortified formula offered by this facility. I give permission for the

formula to be mixed and/or bottles to be prepared for my infant by this facility’s

staff.

_____ I will not use the iron-fortified formula offered by this facility.

If not, which formula will you send for your infant?

If the formula you provide is a special formula, a medical statement will be

requested.

_____ My infant is four (4) months old or older and is developmentally ready for baby

foods. I want the institution/facility to provide the following baby food(s) for my

infant, which are allowed under 7CFR §226.20 (b) (2) (3) (4).

Allowable foods for infants are: iron-fortified infant cereal, fruit, vegetable, meats

or meat alternates, enriched or whole grain bread and crackers. Foods shall be

of appropriate texture and consistency to meet developmental needs.

Baby foods provided by institution/facility must be in compliance with the infant

meal pattern as required by 7CFR §226.20.

Infant’s Name __________________________________________________________

Infant’s Age ___________________________

Parent’s Signature _______________________________ Date __________________

*Note to parents who are getting formula through the WIC Program: Your baby is eligible to get formula from this child

care institution/facility as well as from the WIC Program It is your decision which formula you want your baby to use when

she/he is at child care. If you find that you are getting more formula than your baby needs, you may wish to talk with your

WIC nutritionist or your child care institution/facility.

DHHS CACFP (01/09)

SNP Provision Infant Formula Form

Provision Of Infant Formula Form