FCO Main INFANT Admission JUST INFANT FORMS

Which school does your child attend?*
Child's Full Name*
Child's Date of Birth*

MonthDayYear
Date
FOR CHILDREN ONLY - INFANT FORMS

These forms are required for all infants starting care at FCO. Since there are different governmental entities, there is some repeating information, so please fill out as much as possible.

INFANT DOCUMENT #1: INFANT CARE INSTRUCTION SHEET

This form must be completed by a parent/guardian every 30 days while the infant is in care.

**FOOD ALLERGIES MUST BE IN PAGE 3 of Admissions Packet – Under “8. Child’s Special Care Needs” ** If they are not listed, please go back and fill out this section in the first document.
Current Infant Meal Type:*

Breast MilkFormula
Type of Formula:
Diet:
Cereal:
Fruit:
Vegetables:
Meats:
Types of Food/Quantity:
Breakfast:
Time Served:
Mid-Morning Meal:
Time Served:
Lunch:
Time Served:
Mid Afternoon Meal:
Time Served:
Sleeping Position: (*We always put infants to sleep on their backs unless you provide Form 3019, Infant Sleep Exception/Health Care Professional Recommendation - https://www.hhs.texas.gov/regulations/forms/3000-3999/form-3019-infant-sleep-exceptionhealth-care-professional-recommendation, signed by the infant's health care professional [TMS Section 746.2427 and 747.2327]*

On BackOn SideStomach
Pacifier Use:

YesNo
Special Instructions for feeding and napping:
Parent Signature*

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Date Signed

MonthDayYear
Date
Parent Name
INFANT DOCUMENT #2: CACFP INFANT FEEDING PREFERENCE
Dear Parent/Guardian,

This child care provider participates in the Child and Adult Care Food Program (CACFP) and receives USDA reimbursement for serving nutritious meals to infants according to program requirements. Participation in this program requires child care providers to follow specific meal patterns according to the age of the infant.

If your child is exclusively breastfed, child care providers participating in the CACFP can feed your infant the breast milk you supply and meet the meal pattern requirements. Breastfeeding is widely recognized as the best source of nutrition for infants.

The Institute of Medicine and the American Academy of Pediatrics recommends that adults/caregivers, who work with infants and their families, promote and support exclusive breastfeeding for the first six months and continuation of breastfeeding in conjunction with complementary foods for 1 year or more, and the Texas Department of Agriculture (TDA) encourages child care providers to dedicate a space for mothers to breast feed their infants on site.

Child care providers participating in the CACFP are required to offer at least one infant formula for infants who are enrolled for child care. You may decline the infant formula offered, and supply breast milk and/or your own preferred infant formula.

Additionally, when you determine in consultation with your physician that your child is developmentally ready, the child care provider will also be required to offer infant cereal and other foods. As with infant formula, you can decline the infant cereal and other foods offered and provide those items to your child care provider. It is important to note that your child care provider will not receive reimbursement for meals that contain more than one parent provided component. Speak to your child care provider to understand what components are required for your infant’s meal and the exceptions made for infants with disabilities, so that your infant receives the most nutritious meal possible.

It is very important that you indicate your preferences on the form that follows so we can

honor the nutrition choices you have made for your family. Please complete the information below to designate your preference for infant formula, infant cereal, and other foods.
Center/Provider Name: For Children Only

This child care provider offers the following infant formula(s):

Member's Mark Sensitivity Premium Baby Formula
Member's Mark, Infant Premium, Infant Formula
Member's Mark, Gentle Premium Infant Formula
Child's Full Name
Child's Date of Birth

MonthDayYear
Date
Today's Date (CACFP Infant)

MonthDayYear
Date
Breastmilk and/or Formula Preference

Choose all that apply
I will bring expressed breast milk for my infant.

Birth through 5 months6 - 11 months
I want the child care provider to provide the infant formula it offers for my infant.

Birth through 5 months6 - 11 months
I will bring the infant formula for my infant. Please list the kind of infant formula you will bring: (Birth through 5 months)
I will bring the infant formula for my infant. Please list the kind of infant formula you will bring: (6 - 11 months)
Preference regarding infant cereal and other foods:

My child is developmentally ready for solid foods. I want the child care provider to provide the infant cereal and other foods for my infant.My child is developmentally ready for solids. I will bring the infant cereal and/or other foods for my infant.My child is NOT developmentally ready for solid foods. I will inform the provider when and designate the solid food(s) to be introduced to my infant at that time.
Parent Signature*

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Date Signed

MonthDayYear
Date
1. This form must be kept on file for each infant enrolled for child care. 2. This form must be kept current and accurate for each infant enrolled for child care until the infant reaches one year of age. 3. If the parent (or guardian) provides expressed breast milk and the child care provider feeds it to the child, and/or if the mother breast feeds her child on site, the meal may be claimed for reimbursement. 4. If the parent (or guardian) declines the formula and the child care provider provides meal and/or snack components, the meal may be claimed for reimbursement. 5. If the parent (or guardian) declines infant meals/snack, meals and snacks may NOT be claimed for reimbursement.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD 3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad 3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or (2) fax: (833) 256-1665 or (202) 690-7442; or (3) email: Program.Intake@usda.gov. This institution is an equal opportunity provider.
Operational Policy on Infant Safe Sleep
Please review the following statement/policy and sign below.
• If an infant needs extra warmth, use sleep clothing (insert sleep clothing that will be used such as sleepers or footed pajamas) as an alternative to blankets [Sections 746.2415(b) and 747.2315(b)
Privacy Statement
Signature — Parent*

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HHSC values your privacy. For more information, read our privacy policy online at: https://hhs.texas.gov/policies-practices-privacy#security.
This policy is effective on
Child's Full Name*
Child's Full Name
Date Signed*

MonthDayYear
Date
Should be Empty:

Diet:

Types of Food/Quantity:

INFANT DOCUMENT #2: CACFP INFANT FEEDING PREFERENCE

Breastmilk and/or Formula Preference

Operational Policy on Infant Safe Sleep

Privacy Statement