Playful Plates Club Food Preferences Form
Playful Plates Club is an 8 week group where children from 6-8 years old can learn to try new foods with peers led by an occupational therapist. The 8 week session cost is $280 which includes the price of food purchased by us. Payment required at the time of signing up. First session runs from June 4th- July 23rd. Please be sure to click SUBMIT at the bottom of this form.
Child's Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Parent/ Guardian
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
List any food allergies that we should be aware of:
*
Do you supplement nutritional needs with drinks/powders/etc.? List below.
*
How often does your child eat the follow food categories?
*
Rows
Almost never
Sometimes
Almost always
Carbs
Fruit
Vegetables
Meats
Dairy
Snacks
Desserts
Top 5 favorite foods
*
Cereal
Muffins/donuts
Pancakes/waffles
Bread/toast
PB & J sandwich
Veggies
Fruits
Cheese stick/slice
Yogurt
Pouches (fruit/veg blend)
Milk
Crunchy snacks (crackers, pretzels, chips, etc.)
Dips (PB, hummus, ranch, etc.)
Chicken nuggets
Pizza
French fries
Buttered noodles
Macaroni and cheese
Desserts
Tacos
Does your child sit for meals?
*
yes
no
sometimes
Is your child constantly on the go and/or fidgeting
*
yes
no
sometimes
Does your child touch all food textures (wet, dry, sticky)?
*
yes
no
some textures, not all
Is your child sensitive to...
*
Smell of foods
Feel of foods (only eats 1-2 different textures)
Sight of foods (has to be same brand, same shape, etc.)
Taste preference includes:
*
Salty
Sweet
Bold
Sour
Spicy
Bland
List any behavioral needs at mealtimes (throwing, yelling, crying, anxiety, etc.).
*
Anything else we should know about your child?
Submit
Should be Empty: