Infant Feeding Instructions

This form is for infants ages newborn to 17 months. It must be updated at least every
30 days (or sooner if dietary habits/needs change) until each infant turns 18 months
old.

Required fields are indicated with a “*“.

Child admission ID: *

Date of Birth: *(Please enter a date in mm/dd/yyyy format only)

My child should only be fed the following:

Breastmilk

FormulaBrand

MilkType (whole, soy, etc.)

Food from home

Emerson Snacks (age appropriate)

My child should not be fed the following foods due to allergies, religious beliefs or family concern (if nothing mark ‘Not Applicable’):

My child should be fed (how often and amount). You may be very specific or write “on demand”:

My child may be fed more/less often if:

He or she is fussy

He or she is showing signs of hunger (reaching for food, crying for another child’s bottle, etc.)

He or she communicates that they are hungry (pointing, signing and/or asking for food/drink)

ALL of the above

Not Applicable, My child is on a strict schedule and must be fed accordingly

Consent by Parent

Parent or Guardian Name:*

Relationship to infant:

Get Help

1 Valley View Drive Round Rock, Texas 78664
(512) 252-0400
(512) 252-0401
director@emerson-academy.com
Monday – Friday: 7:00 AM – 6:00 PM

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Website last updated : 11/22/2019

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