Infant Declaration Form 2023

Which location are you enrolling at?*

Infant's full name*

Infant's Date of Birth*

Date

Parent's full name*

My Child is allergic to the following foods: A Doctor's note is required for any foods that cannot be substituted within the same food group*

Your child care provider offers the following infant formula(s)*

Parent Declaration - Select only ONE of the following options.r*

Center will provide ALL meal components for infant named above.Parent will provide ALL meal components for infant named above.BOTH PARENT and CENTER will provide meal components for infant named above.

Which age bracket does your child currently fall into?*

0-5 months6-11 months

Please choose who will provide each meal components for the infant named above.*

	Center	Parent
Iron Fortified Infant Formula/Breast Milk

If provided, what type.

Infant FormulaBreast Milk

Infant formula Brand Name

Please choose who will provide each meal components for the infant named above.*

	Center	Parent
Fortified Infant Cereal
Infant Meats
Crusty Break/Crackers
Infant Fruits/Vegetables

This form must be updated and submitted any time there is a change in Section 2.

I understand that once my infant child turns 6 months of age, it is my responsibility to notify the child care center director as to any limitations of solid foods that my infant child is not developmentally ready to receive.

Parent Signature*

Parent Phone Number*

Date*

Date