Infant Plan
2021
Date
*
-
Month
-
Day
Year
Date
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Bottles/Fluids
Will child be taking bottles at daycare?
*
Yes
No
Does child take bottle at home?
*
Yes
No
Please explain.
*
Will bottles be warmed?
*
Yes
No
Does child hold their own bottle?
*
Yes
No
What type of fluids does your child take in their bottle?
*
Breast Milk
Formula
Other
What brand/type of formula does your child take?
*
How many ounces are in each bottle. Please make sure you update this as your child's feedings change.
I understand that I am responsible for providing, preparing, and labeling all bottles given to my child. Please sign:
*
Solid Foods from Home
Will child be eating solids, food from home, or school food while at daycare?
*
Yes
No
Does child eat solids at home?
*
Yes
No
Please explain.
*
Can your child feed themselves?
*
Yes
No
Which of the following has your child been successfully introduced to?
*
Strained Foods
Baby Food
Formula
Whole Milk
Table Food
Breast Milk
Other
Have you spoken with your child's pediatrician/primary caregiver to ensure that they have met all of the following appropriate developmental skills for the introduction of solid foods?
*
Can hold his/her head steady
Opens mouth/leans forward in anticipation of food offered
Closes lips around spoon
Transfers food from front of the tongue to the back and swallows
I understand that I am responsible for providing, preparing, and labeling all solids and food from home given to my child. Please sign:
*
Schedule
Which school-provided meals would you like for your child to participate in?
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Breakfast (8:00am)
Lunch (11:00am)
Afternoon Snack (1:30pm)
Evening Snack (4:30pm)
My child will not be participating in school-provided meals.
Please list your child's feeding/sleep schedule below. Use as much detail as possible, listing the exact time or frequency of feedings/naps. Include nap times, bottles/amounts, school-provided meals, and all snacks from home. Please list the ounces of each of your child's bottles. If your child's feeding/sleep schedule is "On-Demand," please note the maximum amount of time your child can go between feedings. For example on demand but no more than 3 hours between feedings.
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For example: 7am- one baby food solid (from home), 8:30am- 6oz bottle (from home), 9am-10:30am- nap (self-soothe), 12:30pm- one baby food solid with 1 teething cracker (from home), 1:30pm- afternoon snack (from school), 2:30pm- 6oz bottle (from home), 3pm-4pm- nap (self soothe), will be picked up before next feeding.
If my child is sleeping during scheduled feeding times, I prefer my child to:
*
be woken up
be left sleeping
Maximum amount of time to be left sleeping:
*
I understand that I am responsible for updating my child's schedule as it changes and at least every month. Please sign:
*
Other
Does child take pacifier?
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Yes
No
When does child take pacifier?
*
Food Likes:
*
Food Dislikes:
*
Does your child have any allergies?
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Yes
No
Please list child's allergies (including any premixed formula):
*
I have read and agree to The Infant Safe Sleep Policy.
*
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