KD'S INFANT FORMULA & FOOD FORM

Infant's Name:*

First NameLast Name

DOB:*

Child Care Provider*

To Parents/Guardians of infants, birth through 11 months old
Your child’s care provider participates in the Child and Adult Care Food Program (CACFP). The CACFP is administered by the District of Columbia Office of the State Superintendent of Education and is funded by the United States Department of Agriculture (USDA). The CACFP subsidizes the cost of the healthy meals prepared and served to your infant while in care. Your provider follows the USDA Meal Pattern Requirements for Infants (see below), as age and developmentally appropriate for your child.

As a participant in the CACFP, your provider must offer formulas and meals to all enrolled infants and children.

USDA Meal Pattern Requirements for Infants
Age	Breakfast	Lunch or Supper	Snack
0–5 months	4–6 fluid ounces formula or breast milk		4–6 fluid ounces formula or breast milk
6–11 months	6–8 fluid ounces formula or breast milk AND 0–2 Tbsp fruit or vegetable or both AND 0–4 Tbsp iron fortified infant cereal, meat, fish, poultry, egg yolk, cooked dry beans or 0–2 oz cheese or 0–4 oz (volume) cottage cheese or 0–4 oz or 1/2 cup of yogurt, or a combination of the above		2–4 fluid ounces formula or breast milk AND 0–2 Tbsp fruit or vegetable or both AND ½ slice bread, or 0–2 crackers, or 0–4 Tbsp infant cereal or ready-to-eat breakfast cereal

PARENT FORMULA REQUEST

USDA supports and encourages mothers to continue breastfeeding when returning to work or school. You have the option to breastfeed your infant at the center, bring your own formula or breast milk, or use the provider-supplied formula. The provider offers the formula listed below.

Name of provider-supplied formula:*

AcceptDecline

If you DECLINE, list the brand of formula you will provide, or breast milk, or identify if you breastfeed on site:

ACCEPT all foodsDECLINE all foods

Signature of Parent or Guardian*

Printed Name of Parent / Guardian*

Date*

Date

First Food Check-In

Age of Infant*

Developmental Readiness Indicators

Indicators from HealthyChildren.org by the AAP

YesNo

If yes, select components and list which food items you have introduced to your infant?

Rows	Check below	Food items to introduced
Iron-fortified infant cereal and/or grains
Meat/meat alternates
Fruits
Vegetables

If yes, are there any foods that you do not want the institution to serve your infant? For example: beef, carrots, strawberries.

Rows	Check below	Food items to avoid
Iron-fortified infant cereal and/or grains
Meat/meat alternates
Fruits
Vegetables

Comments:

KD'S INFANT FORMULA & FOOD FORM

Parent Food Request