Infant Foods Provided by Parent

Effective October 1, 2017, parents/guardians may supply (but are not required to supply) one meal component for their infant. You must provide all other required meal components in order for the meal service to be reimbursable. You can update information for up to five different children.

I HEREBY CERTIFY to the best of my knowledge that this information is true, correct, and in accordance with the terms of our existing agreement and that records are available to support this information. I understand that this information is being given in connection with the receipt of federal funds and that deliberate misrepresentation may subject me to prosecution under applicable state and federal criminal statutes.”

Infant Foods Provided by Parent Form

Number of Children

Your Six-Digit WECA CACFP Provider Number

Your First and Last Name

Infant #1 Name and ID#

Infant #1 Date

Infant #1 Breakfast Infant #1 Breakfast Infant #1 Breakfast

Infant #1 List all infant breakfast foods provided by the parent, including formula and/or breast milk.

Infant #1 A.M. Snack Infant #1 A.M. Snack Infant #1 A.M. Snack

Infant #1 List all infant a.m. snack foods provided by the parent, including formula and/or breast milk.

Infant #1 Lunch Infant #1 Lunch Infant #1 Lunch

Infant #1 List all infant lunch foods provided by the parent, including formula and/or breast milk.

Infant #1 P.M. Snack Infant #1 P.M. Snack Infant #1 P.M. Snack

Infant #1 List all infant p.m. snack foods provided by the parent, including formula and/or breast milk.

Infant #1 Dinner Infant #1 Dinner Infant #1 Dinner

Infant #1 List all infant dinner foods provided by the parent, including formula and/or breast milk.

Infant #1 Evening Snack Infant #1 Evening Snack Infant #1 Evening Snack

Infant #1 List all infant evening snack foods provided by the parent, including formula and/or breast milk.

Infant #2 Name and ID#

Infant #2 Date

Infant #2 Breakfast Infant #2 Breakfast Infant #2 Breakfast

Infant #2 List all infant breakfast foods provided by the parent, including formula and/or breast milk.

Infant #2 A.M. Snack Infant #2 A.M. Snack Infant #2 A.M. Snack

Infant #2 List all infant a.m. snack foods provided by the parent, including formula and/or breast milk.

Infant #2 Lunch Infant #2 Lunch Infant #2 Lunch

Infant #2 List all infant lunch foods provided by the parent, including formula and/or breast milk.

Infant #2 P.M. Snack Infant #2 P.M. Snack Infant #2 P.M. Snack

Infant #2 List all infant p.m. snack foods provided by the parent, including formula and/or breast milk.

Infant #2 Dinner Infant #2 Dinner Infant #2 Dinner

Infant #2 List all infant dinner foods provided by the parent, including formula and/or breast milk.

Infant #2 Evening Snack Infant #2 Evening Snack Infant #2 Evening Snack

Infant #2 List all infant evening snack foods provided by the parent, including formula and/or breast milk.

Infant #3 Name and ID#

Date

Infant #3 Breakfast Infant #3 Breakfast Infant #3 Breakfast

Infant #3 List all infant breakfast foods provided by the parent, including formula and/or breast milk.

Infant #3 A.M. Snack Infant #3 A.M. Snack Infant #3 A.M. Snack

Infant #3 List all infant a.m. snack foods provided by the parent, including formula and/or breast milk.

Infant #3 Lunch Infant #3 Lunch Infant #3 Lunch

Infant #3 List all infant lunch foods provided by the parent, including formula and/or breast milk.

Infant #3 P.M. Snack Infant #3 P.M. Snack Infant #3 P.M. Snack

Infant #3 List all infant p.m. snack foods provided by the parent, including formula and/or breast milk.

Infant #3 Dinner Infant #3 Dinner Infant #3 Dinner

Infant #3 List all infant dinner foods provided by the parent, including formula and/or breast milk.

Infant #3 Evening Snack Infant #3 Evening Snack Infant #3 Evening Snack

Infant #3 List all infant evening snack foods provided by the parent, including formula and/or breast milk.

Infant #4 Name and ID#

Infant #4 Date

Infant #4 Breakfast Infant #4 Breakfast Infant #4 Breakfast

Infant #1 List all infant breakfast foods provided by the parent, including formula and/or breast milk.

Infant #4 A.M. Snack Infant #4 A.M. Snack Infant #4 A.M. Snack

Infant #4 List all infant a.m. snack foods provided by the parent, including formula and/or breast milk.

Infant #4 Lunch Infant #4 Lunch Infant #4 Lunch

Infant #4 List all infant lunch foods provided by the parent, including formula and/or breast milk.

Infant #4 P.M. Snack Infant #4 P.M. Snack Infant #4 P.M. Snack

Infant #4 List all infant p.m. snack foods provided by the parent, including formula and/or breast milk.

Infant #4 Dinner Infant #4 Dinner Infant #4 Dinner

Infant #4 List all infant dinner foods provided by the parent, including formula and/or breast milk.

Infant #4 Evening Snack Infant #4 Evening Snack Infant #4 Evening Snack

Infant #4 List all infant evening snack foods provided by the parent, including formula and/or breast milk.

3 + 9 =