[heading "CACFP Infant Enrollment Form"]

    *Your Name

    *Infants Name

    *Email

    *Your Phone Number

    *Infants Birthdate

    [heading "Breast Milk or Formula Preference"]

    [heading "Inital And Date All That Apply"]

    [heading "*I will provide breast milk for my infant"]

    N/A

    N/A

    Birth - 5 Months

    Birth - 5 Months

    6-11 months

    6-11 months

    [heading "*I Will Breast Feed My Child"]

    N/A

    N/A

    Birth - 5 Months

    Birth - 5 Months

    6-11 months

    6-11 months

    [heading "*I want the childcare center/provider to provide the infant formula it offers for my infant"]

    N/A

    N/A

    Birth - 5 Months

    Birth - 5 Months

    6-11 months

    6-11 months

    [heading "*I will provide the infant formula for my infant. (must be iron fortified)"]

    N/A

    N/A

    Birth - 5 Months

    Birth - 5 Months

    6-11 months

    6-11 months

    Name of Formula Parent Will Provide

    [heading "*My infant has a special dietary need that requires a formula that does not meet the criteria for an approved iron fortified formula. I have provided the center/provider with a Medical Plan of Care signed by a licensed medical authority that includes the impairment that restricts the infant's diet, how it effects the infant, and the recommended substitution. Name of infant formula I will provide "]

    N/A

    N/A

    Birth - 5 Months

    Birth - 5 Months

    6-11 months

    6-11 months

    Name of Non-Iron Fortified Formula I Will Provide

    [heading "Preference regarding infant cereal and other foods "]

    [heading "Record date to indicate your preference *l understand that I may change my decision at any time without advance notice"]

    [heading "*I want the childcare center/provider to provide the iron fortified infant cereal and other foods for my infant."]

    N/A

    N/A

    6-11 months

    6-11 months

    [heading "*I want the childcare center/provider to provide all food items with one exception. (This option is only applicable if center/provider is providing the iron fortified infant formula."]

    N/A

    N/A

    6-11 months

    6-11 months

    One food item that I will provide (must be creditable CACFP food item:

    [heading "*My infant has a special dietary need that requires modifications to the infant meal pattern requirements. I have provided the center/provider with a Medical Plan of Care signed by a licensed medical authority that includes the impairment that restricts the infant's diet, how it effects the infant, the food to avoid and the recommended substitutions."]

    N/A

    N/A

    6-11 months

    6-11 months

    [heading "* I am aware and understand that all the information provided on this form and my ability to have my infant participate in the CACFP, however I decline the infant formula and food offered by the center/provider and elect to furnish ALL infant formula and food for my infant. (Center/Provider may not claim meals for this infant)"]

    N/A

    N/A

    6-11 months

    6-11 months

    * Parent/Guardian Sig

    * Parent/Guardian Date