"Infant Affidavit" - Georgia (United States)

Infant Affidavit is a legal document that was released by the Georgia Department of Early Care and Learning - a government authority operating within Georgia (United States).

Form Details:

  • Released on October 1, 2017;
  • The latest edition currently provided by the Georgia Department of Early Care and Learning;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Georgia Department of Early Care and Learning.

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Download "Infant Affidavit" - Georgia (United States)

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Infant Affidavit
Name of Sponsor (if applicable) _____________________________________________
Name of Provider/Center ___________________________________________________
Name of Infant: _________________________________
Infant Date of Birth: ______________________________
Name of Parent/Guardian:
According to USDA regulations, as an institution participating in the Child and Adult Care Food Program
must provide meals to all infants enrolled for care in the center/facility.
Center/provider will provide the following milk-based iron-fortified formula: ______________________
Center/provider will provide the following Iron-fortified infant cereal: ___________________________
Center/provider will provide the following brand of infant foods: _______________________________
_____________________________________________________________________________________
Parents/Guardians,
Please check one of the following options below and sign this form:
_______ I would like the provider/center to provide ALL meal components to my infant and I will
provide clean, sanitized, and labeled bottles daily.
_______ I will provide the following meal component to my infant and the center will provide all other
meal components:
 Formula*
 Meat/Fish/Poultry/Eggs/Beans/Peas
 Cereal
 Cheese/Cottage Cheese/Yogurt
 Fruit
 Bread/Crackers/Breakfast Cereal
 Vegetable
_______________________________________
__________________
Parent/Guardian Signature
Date
*Any parent requesting any formula other than a USDA approved milk-based or soy-based iron-fortified
formula be provided to their infant or any parent who provides any formula other than a USDA approved
milk-based or soy-based iron-fortified formula for their infant must provide a doctor’s note indicating the
required use of the formula. If a parent elects to have the center or day care home provider supply meals
to their infant, the infant will be fed according to its individual feeding plan that is provided by the parent
or guardian. The center or day care home provider may only claim reimbursement for no more than
breakfast, lunch or supper, and a snack.
Sample Infant Affidavit – Updated October 2017
Infant Affidavit
Name of Sponsor (if applicable) _____________________________________________
Name of Provider/Center ___________________________________________________
Name of Infant: _________________________________
Infant Date of Birth: ______________________________
Name of Parent/Guardian:
According to USDA regulations, as an institution participating in the Child and Adult Care Food Program
must provide meals to all infants enrolled for care in the center/facility.
Center/provider will provide the following milk-based iron-fortified formula: ______________________
Center/provider will provide the following Iron-fortified infant cereal: ___________________________
Center/provider will provide the following brand of infant foods: _______________________________
_____________________________________________________________________________________
Parents/Guardians,
Please check one of the following options below and sign this form:
_______ I would like the provider/center to provide ALL meal components to my infant and I will
provide clean, sanitized, and labeled bottles daily.
_______ I will provide the following meal component to my infant and the center will provide all other
meal components:
 Formula*
 Meat/Fish/Poultry/Eggs/Beans/Peas
 Cereal
 Cheese/Cottage Cheese/Yogurt
 Fruit
 Bread/Crackers/Breakfast Cereal
 Vegetable
_______________________________________
__________________
Parent/Guardian Signature
Date
*Any parent requesting any formula other than a USDA approved milk-based or soy-based iron-fortified
formula be provided to their infant or any parent who provides any formula other than a USDA approved
milk-based or soy-based iron-fortified formula for their infant must provide a doctor’s note indicating the
required use of the formula. If a parent elects to have the center or day care home provider supply meals
to their infant, the infant will be fed according to its individual feeding plan that is provided by the parent
or guardian. The center or day care home provider may only claim reimbursement for no more than
breakfast, lunch or supper, and a snack.
Sample Infant Affidavit – Updated October 2017