shalom daycare

Shalom Daycare Enrollment Packet This packet can be submitted electronically through email: [email protected] or physically at the address below: Shalom Daycare Ministry Roberts Park United Methodist Church 401 North Delaware Street Indianapolis, IN 46204

Child’s Name: _________________________ 1

Table of Contents

Enrollment Agreement Pg. 2-4 Family Information Pg. 5-6 Health Form Pg. 7-9 Transportation Policy Pg. 10 Safe Conditions Policy Pg. 11 Discipline and Guidance Policy Pg. 12 Photo Release Form Pg. 13 Preschool Checklist Pg. 14 Parent’s Notice (state form 49444) Pg. 15 Physical Form (state form 49969) Pg. 16-17 Record of Medication Order (state form 49968) Pg. 18 Infant Daycare Supplemental Forms Pg.19 Infant Checklist Pg. 20 Infant Sleep Position Policy Pg. 21-22 Infant Feeding Plan (state form 49963) Pg. 23-24 Breastmilk Procedure (state form 49954) Pg. 25

Child’s Name: _________________________ 2

Enrollment Agreement

Child Information Name of Child: ________________________________________________________________

First Middle Last Name child is called: ___________________________________________________________

Child’s Date of Birth: ___________________________________________________________

Address: _____________________________________________________________________ Street City State Zip Code

Parent Information Parent’s Name: _________________________ Email Address: _______________________


Place of Employment: __________________________________________________________

Home phone: ___________________________ Work Phone: __________________________

Cell Phone: __________________________

Parent’s Name: _________________________ Email Address: _______________________


Place of Employment: __________________________________________________________

Home phone: ___________________________ Work Phone: __________________________

Cell Phone: __________________________

Child’s Name: _________________________ 3 Names and phone numbers of persons to whom we may release your child:

Name Phone Number Relationship to child

Emergency/Medical Contact Physician ___________________________ Phone Number: __________________________

If we need to take your child to a hospital in an emergency, do you have a preferred hospital? _____________________________________________________________________ Primary Emergency Contact Name: _______________________________________________

First Name Last Name

Relationship to child: ________________________ Home phone: ______________ Cell: _______________ Work phone: _______________

Secondary Emergency Contact Name: _____________________________________________



Tertiary Emergency Contact Name: _______________________________________________



Insurance Information

Company: _________________________ Policy Number: ____________________________

Comments: (include any special medical or personal information you would want an emergency care provider to know or special contact information): ______________________ _____________________________________________________________________________

Child’s Name: _________________________ 4

Additional Information

How did you hear about Shalom Daycare Ministry: __________________________________

We expect that you will honor your enrollment for at least a one-year term unless you move from the city or some unusual circumstance makes a mutual agreement to dissolve the contract the most advantageous arrangement for your child. We also expect that you will inform us of any change concerning the information in your child’s file. I have read the PARENT HANDBOOK and agree to abide by all the policies and terms concerning the fee and payment schedule, late fees, discipline policy, and vacation policies as outlined by Shalom Daycare Ministry Parent Handbook and I agree to honor this enrollment agreement as described above. Date ___________________________ Signed: _____________________________________

Parent or Legal Guardian Registration Fee: $___________________________ Date Paid: _________________________

Weekly Tuition Fee: $___________________________

Materials Fee: $___________________________ Date Paid: _________________________

For Office Use Only ______________ Enrollment form signed and fees received

______________ Agreement for emergency treatment signed and received

______________ Family information received

______________ Health form received

Child’s Name: _________________________ 5

Family Information You can help us plan for your child’s needs, understand concerns and responses, and support and encourage your child if you provide the following information. The information will remain confidential and we ask that you will update it whenever there are any changes.

Parent’s Name: ________________________________________________________________

Parent’s Name: ________________________________________________________________

Marital status of parents:

_______ Married, living together _______ Separated _______ Divorced

If divorced, please describe the custody and visitation agreement for your child: ________________________________________________________________________

Others in your household Siblings (names and ages): _______________________________________________________

_____________________________________________________________________________

Other adults (names, ages, and relationship to your child) :____________________________

_____________________________________________________________________________

Other significant persons in your child’s life (stepfamilies, grandparents, babysitters, etc.)

_____________________________________________________________________________

_____________________________________________________________________________

Does your child have pets? Please give their names and kinds:

_____________________________________________________________________________

_____________________________________________________________________________

Child’s Name: _________________________ 6

Additional Information Have there been births, deaths, adoptions, or other changes in the family structure which affected your child? If yes, please describe briefly what happened and how its effects on your child. _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

What opportunities does your child have to play with other children?

_______ Neighborhood _______ Sunday School/Church _______ Nursery School or other classrooms _______ Other

What are your child’s favorite play activities? ______________________________________

____________________________________________________________________________

What methods of discipline have you found most effective? __________________________

____________________________________________________________________________

What fears does your child have and how are they expressed? ________________________

____________________________________________________________________________

What do you and your child enjoy doing together? __________________________________

____________________________________________________________________________

Child’s Name: _________________________ 7

Health Form You can help us plan for your child’s needs, understand concerns and responses, and support and encourage your child if you provide the following information. The information will remain confidential and we ask that you will update it whenever there are any changes. How many hours of sleep per day does your child require? ____________________________

Does your child nap regularly? ____________________________

What is your child’s usual bedtime? ____________________________

What communicable diseases has your child had? Indicate date or age:

Chicken pox: ___________ Mumps: ___________

Measles: ___________ Impetigo: ___________

Conjunctivitis (pink eye): ___________

Does your child have frequent:

Colds: ___________ Coughs: ___________

Tonsillitis: ___________ Ear Infections: ___________

Upset Stomach: ___________ Convulsions: ___________

High Fever: ___________ Seizures: ___________

Has your child had serious illness, surgery, or hospital stay? If yes, please describe the condition(s) and your child’s reaction(s): __________________________________________ ____________________________________________________________________________

Does your child have any abnormality of any of the following: Skin: ___________ Glands: ___________ Extremities: ___________ Genitalia: ___________ Nervous System: ___________ If yes to any, please describe: __________________________________________

___________________________________________________________________

Child’s Name: _________________________ 8

Are bowel and bladder functions regular and under control? __________________________

Has your child had a vision test? ___________ Results: ____________________________

Has your child had a hearing test? ___________ Results: ____________________________

Has your child had regular dental check-ups? ___________

Any problems? ___________________________________________________________

Is your child taking any medication regularly? _______________

If yes, please state the name of each medication with the dose and frequency given.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Does your child have allergies? ___________ If yes, to what substances? _______________

How are allergies manifested? (sneezing, hives, upset stomach, asthma, etc.) ____________

____________________________________________________________________________

____________________________________________________________________________

Does your child have any dietary restrictions? _______________

If yes, please describe: ____________________________________________________

_______________________________________________________________________

Are these restrictions due to allergy, family preference, medical needs, other?

_______________________________________________________________________

Describe your child’s eating habits:

Likes lots of foods: ___________ Eats only a few foods: ___________

Eats only at mealtimes: ___________ Snacks all day: ___________

Child’s Name: _________________________ 9 Describe your child’s overall health: ______________________________________________ _____________________________________________________________________________

_____________________________________________________________________________

Please provide any additional information that you think might be important for us to have:

_____________________________________________________________________________

_____________________________________________________________________________

What hopes and expectations do you have for your child if they participate in our program?

_____________________________________________________________________________

_____________________________________________________________________________

Permission for Emergency Medical Treatment In the event of an illness or accident which requires immediate medical treatment at a time when a parent cannot be located, I give permission for the Director of Shalom Daycare ministry, or other Shalom Daycare personnel designated by the Director, to authorize such treatment. I will not hold Shalom Daycare Ministry nor any medical personnel responsible. This permission is given with the understanding that every attempt will have been made to contact the parents, the child’s physician, and other persons listed for emergency contact. Date: __________________ Signed: _______________________________________

Child’s Name: _________________________ 10

Transportation Policy Our child care does not provide vehicle transportation to school or other extracurricular activities. Our children will occasionally take walking field trips. in the event of a walking field trip, a separate form will need to be signed by a parent or guardian for each child participating. Without a signed permission slip, children will not be allowed to walk off of our premises. Parents are always invited and welcome to join on our field trips.

Our younger children may occasionally take stroller rides around the block surrounding the church. The children will not cross any street during these walks. The walks may include going east or west on Vermont street, north or south on Delaware street, east or west on Michigan street, and north or south on Alabama street.

Child/staff ratio will be maintained at all times.

Date: __________________ Signed: _______________________________________

Child’s Name: _________________________ 11

Safe Conditions Policy The following steps will be taken to ensure that your child is safe while at our child care program.

Children will be actively supervised with the required number of qualified adults (adults who have completed comprehensive criminal history check, drug screen, and negative TB test, and have completed all required trainings).

Our child care will not care for children in areas that are being remodeled, repaired, or painted. The administrator or director is responsible for maintaining all interior and exterior surfaces, including walls, floors, ceiling, equipment, toys, furnishings and cribs, in a safe condition, free of sharp points or jagged edges, splinters, protruding nails or wires, loose parts, rusty parts, or materials containing poisonous substances.

The child care will take the following steps to maintain the child care:

1) Clean the child care daily 2) Keep the child care in a sanitary condition at all times 3) Sanitize toys, furniture, and other equipment used by children, weekly and when they

become soiled or contaminated 4) Wash all soiled items prior to sanitization

If you have additional questions about providing daily activities and maintaining a safe environment, please call the Office of Early Childhood and Out of School Learning at 877-511-1144. You can also find additional information and resources about daily activities and safe conditions at the following websites: Office of Early Childhood and Out-of-School Learning: Information on becoming or finding a childcare provider. Additional information/resources, laws, and reports.

https://www.in.gov/fssa/carefinder/ Caring For Our Children: National health and safety performance standards guidelines for early care and education programs.

https://nrckids.org/CFOC

Date: __________________ Signed: _______________________________________

Child’s Name: _________________________ 12

Discipline and Guidance Policy At Shalom Daycare Ministry the term guidance instead of “discipline” is used for several reasons. It is a positive term and implies working with the children to develop internal control of their behavior. Our goal is to encourage the children to become independent, responsible, and socially mature human beings. This involves learning to make responsible choices and accepting the consequences of such choices. Guidance takes several forms within our center:

• Environment: A place designed for children. Each room is age-appropriate in furniture size, large and small manipulatives, and supplies required for hands-on experiences.

• Logical Rules: Such as keeping our hands to ourselves and taking care of the learning environment. These are discussed with the children as well as why such rules are needed.

• Curriculum: Is developmentally appropriate, based on the children's interests and level of readiness.

• Positive Behavior: We reinforce the behaviors we wish to see repeated. • Redirection: Often interesting a child in another activity can eliminate potential difficulty.

We might ask a child to help us or send a child a different area to play. • Positive Reminder: Telling the children what we want them to do rather than using “no” or

“don’t.” • Renewal Time: Occasionally, as a last resort, a child needs to be removed from the situation

for a brief time out. This allows the child time to calm down and consider an alternate behavior. If used, time out will be appropriate for tie age and not last longer than the age of the child.

Date: __________________ Signed: _______________________________________

Child’s Name: _________________________ 13

Photo Release Form At Shalom Daycare Ministry and Roberts Park UMC, we occasionally take pictures during daily activities—including field trips and events. Mostly we take pictures to display in classrooms, parent gifts, and for the newsletter. You will receive photos occasionally on your tend.ly feed as well. With the use of the Shalom newsletter, Shalom Facebook page, advertisement materials, and the Roberts Park UMC website, we need specific photo consent for all children enrolled in our program. Please read each description carefully and check the appropriate line for photo permission for your child(ren). _____ My child may be photographed for classroom displays, moments path, and parent gifts only _____ My child may be photographed for classroom use, moments path, parent gifts/any social media use (Shalom Facebook page, Roberts Park website, newsletter) _____My child may be photographed for any reason and the photo may be used outside of Roberts Park UMC and/or Shalom Daycare Ministry (ie: flyers, advertisements, etc…) _____You may use my child’s name with the photo _____You may NOT use my child’s name with the photo _____You may NOT use my child’s photo for any purpose at all I understand that this release will be in effect as long as my child(ren) are enrolled at Shalom Daycare Ministry unless I request and fill out a new form. Date: __________________ Signed: _______________________________________

Child’s Name: _________________________ 14

Preschool Daycare Checklist Please make sure you supply the following for your preschool child. If your child is still an infant, there is a different checklist for you in the “Infant Daycare Supplemental Forms” section on page 21. __________ Blanket for naptime __________ Three (3) complete changes of weather appropriate clothing upon enrollment

and as needed __________ Completed enrollment packet __________ Any medication (prescription and/or over the counter) with a signed doctor note

for administration. We cannot administer any medication without a doctor note. Date: __________________ Signed: _______________________________________

HEALTH CARE PROGRAM FOR CHILD CARE HEALTH RECORD - CHILDState Form 49969 (R5 / 7-19)

Name of child (last, first)

Address (number and street, city, state, and ZIP code)

Child lives with (relationship)

Date of birth (month, day, year) Date of admission (month, day, year)

Name Telephone number

MEDICAL HISTORY

Allergies:

Handicapping conditions:

Other:

Communicable Disease Month / Year Condition Explain if present

PHYSICAL EXAMINATIONDate of exam (month, day, year) Age of child

SkinLymphnodesEyesEarsNasopharynxTeeth and Mouth

HeartLungsAbdomenGenitaliaSkeletonOther:

Note any unusual findings:

Does this child have any health condition that would be hazardous either to the child or to other children in a group setting as a result of participation in normal activities (including sports)?

If Yes, what modification of normal activities would be necessary to protect the child and the child's classmates:

Have you prescribed any medications or special routines which should be included in the center's plans for this child's activities? Explain:

Yes No

Yes No

(Over)

( )

Screenings Result / Date (month, day, year)TB Risk / SymptomDevelopmental ScreenLead

FAMILY AND SOCIAL SERVICESADMINISTRATION - MS02

402 W. Washington St., Room W362Indianapolis, IN 46204

HISTORY OF IMMUNIZATIONS AND TEST (indicate month / day / year)

1 2 3 4 5

DTaP / DT

1 2 3 4 5

IPV (Polio)

1 2Measles MumpsRubella (MMR)

1 2 3 4

Hib

Name of physician / nurse practitioner / physician assistant completing form (please print)

Signature of physician / nurse practitioner / physician assistant

ADDITIONAL NOTES AND INSTRUCTIONS

* Recommended yearly.

1 2 3HBV (HEP B)

1 2Pneumococcal(PCV) (Prevnar)

3 4

1 2 3 4 5

Influenza (Flu)

1 2 3

Rotavirus (RGE)

1 2Varicella (Varivax) or Chicken Pox Disease

Month / year

1 2

HEP A

*

Telephone number

( )

FSSA - MS02402 WEST WASHINGTON STREET, RM W362

INDIANAPOLIS, IN 46204RECORD OF MEDICATION ORDERState Form 49968 (R4 / 7-19)

All medications, medicinal products, physician’s sample medications, and medicinal skin care products given or used at a child care center must include the exact name of medication, dosage to be given, time to be given and reason for use. (If used for fever, the degree of temperature must be stated.) A prescriber order is valid for one (1) year.

1. Name of child Exact name of medication

Dosage to be given Time to be given (frequency)

Reason for use:

Signature of child’s healthcare provider Date (month, day, year)



Reason for use:

Date (month, day, year)



Reason for use:




Reason for use:




Reason for use:


Signature of child’s healthcare provider




Infant Daycare Supplemental Forms

Child’s Name: _________________________ 20

Infant Daycare Checklist Please make sure you supply the following for your infant: __________ Prepared formula or breast milk daily—please include one extra bottle for

emergencies. Bottles must be labeled with child’s name and date daily. __________ Unopened package of disposable diapers—upon enrollment and as needed. __________ Unopened package of disposable baby wipes—upon enrollment and as needed. __________ Three (3) complete changes of weather appropriate clothing upon enrollment

and as needed. __________ Completed enrollment packet—including infant feeding plan signed by doctor. __________ Any medication (prescription and/or over the counter) with a signed doctor note

for administration. We cannot administer any medication without a doctor note. Date: __________________ Signed: _______________________________________

Child’s Name: _________________________ 21

INFANT SLEEP POSITION POLICY Reason this policy is important:

Providing infants with a safe environment in which to grow and learn is of extreme importance to us. Therefore, our child care facility has implemented policies and procedures to create a safe sleep environment for infants. We follow the recommendations of the American Academy of Pediatrics (AAP) and the Consumer Safety Commission for safe sleep environments to reduce the risk of sudden infant death syndrome (SIDS). SIDS is "the sudden death of an infant under 1 year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history."

Procedure and Practices, including responsible person(s):

• Infants less than 12 months of age shall be placed on their backs on a firm tight-fitting mattress for sleep in a crib. Sheets should also be tight fitting.

• Swings, bouncy seats, car seats, rock-n-play sleepers, bassinettes, waterbeds, sofas, soft mattresses, pillows, and other soft surfaces shall be prohibited as infant sleeping surfaces.

• All pillows, quilts, comforters, sheepskins, stuffed toys, and other soft products shall be removed from the crib.

• Blankets are not used in the crib; Blankets, bibs, burp cloths should not hang over the side of the crib.

• The infant's head shall have no covering during sleep (i.e. blankets & bibs, etc..).

• Unless the child has a Medical Waiver on file completed & signed by their physician specifying otherwise, infants shall be placed flat on their back for sleeping to reduce the risks of Sudden Infant Death Syndrome (SIDS).

• When infants can easily turn over from the back to stomach position, they shall be put down to sleep on their back, but allowed to adopt whatever position they prefer for sleep; an "I can roll" sign is suggested above or on the infants crib at this time.

• Unless a doctor specifies the need for a positioning device that restricts movement within the child's crib, such devices shall not be used; this must be on the Medical Waiver and completed/signed from the physician.

• There is no smoking allowed in the child care setting.

• Infants will not share a crib with other children.

• Infants will remain lightly clothed and comfortable while sleeping. Sleep sacks can be used during sleep; however, swaddling sleep sacks may only be used until the child turns 3 months of age. Supervised "tummy time" will be observed while infant is awake.

Child’s Name: _________________________ 22 At the time of application, families of infants will be informed of the programs sleep position rules and given a copy of the policy. All staff will receive training on safe sleep practices before caring for infants and annually.

When the policy applies: This policy applies to all staff and families.

Communication plan for staff and parents: This policy will be reviewed with the parents at the time of enrollment and a copy will be provided in the infant enrollment packet. This policy will be reviewed during annual staff training and new staff orientation.

I have received this policy and understand it is followed at all times within the infant classrooms.

Date: __________________ Signed: _______________________________________

SUPPLEMENTAL HEALTH CARE PROGRAM FOR CHILD CARECENTERS PROVIDING INFANT-TODDLER CARESUGGESTED FEEDING PLANState Form 49963 (R3 / 2-15)

INSTRUCTIONS:Prior to admission, a feeding plan shall be established and written for each infant (age six (6) weeks to twelve (12) months) in consultation with the parents and based on the written recommendation of the child's medical provider. Feeding plans must be continually updated by the child’s medical provider or parent. [470 IAC 3-4.7 (b)]

The following feeding plan has been recommended for this child.

Name of child Date of birth (month, day, year)

Age inMonths

Time toFeed Formula / Food Item and Amount Special Instructions

Signature and Date ofParent or Medical Provider

Signature of MD, DO, NP Date signed (month, day, year)


INDIANAPOLIS, IN 46204

2 MONTHS - 5 MONTHS

INSTRUCTIONS: This is a guideline. Each child will grow at a different rate.1. Formula and juice may be offered in a training cup when a child is ready.2. Formula is used until twelve (12) months unless otherwise stated by a physician.3. Only plain, strained, mashed or chopped vegetables, fruits and meats are offered.4. Most children are ready for foods of coarser consistency between nine (9) to ten (10) months of age. Mashed or chopped table foods may be used.5. Strained or mashed foods may be introduced at six (6) months if the infant's neuromuscular system has developed appropriately. Indications for solid foods are: the ability to swallow non-liquid foods, to sit with support, head and neck control, and to show that the child is able to decline food by leaning back or turning away.6. Finger foods may be offered between nine (9) to twelve (12) months when infant is developing finger / hand coordination.7. The serving of juice to children under twelve (12) months of age is discouraged.

FEEDING PLAN GUIDELINES

TIME INTERVAL AMOUNT EACH FEEDINGMonth 2 Month 3 Month 4 Month 5

6:00 a.m.

10:00 a.m.

2:00 p.m.

6:00 p.m.

10:00 p.m.

2:00 a.m.

4 - 6 oz.

4 - 6 oz.

4 - 6 oz.

4 - 6 oz.

4 - 6 oz.

4 - 6 oz.

4 - 7 oz.

4 - 7 oz.

4 - 7 oz.

4 - 7 oz.

4 - 7 oz.

4 - 7 oz.

5 - 7 oz.

5 - 7 oz.

5 - 7 oz.

5 - 7 oz.

5 - 7 oz.

5 - 7 oz.

5 - 8 oz.

5 - 8 oz.

5 - 8 oz.

5 - 8 oz.

5 - 8 oz.

5 - 8 oz.

6 MONTHS - 12 MONTHSMonth 6 Month 7 Month 8 Month 9 Months 10, 11, and 12

TotalAmount of

Formula Per24 Hours

7:00 a.m.

9:00 a.m.

12:00 Noon

3:00 p.m.

6:00 p.m.

9:00 p.m.

30 - 48 oz. 30 - 32 oz. 29 - 31 oz. 26 - 31 oz. 24 - 32 oz.

5 - 8 oz. formula2 - 3T baby cereal *

5 - 8 oz. formula

5 - 8 oz. formula1/2 dry toast or 2 crackers

5 - 8 oz. formula


5 - 8 oz. formula

6 oz. formula2 - 3T baby cereal *

6 oz. formula

6 oz. formula2 - 3T strained vegetable

6 oz. formula1/2 dry toast or 2 crackers

6 oz. formula2 - 3T strained fruit2 - 3T baby cereal *


1/2 cup Vitamin C fortifiedfruit or juice1/4 dry toast or 1 cracker

7 - 8 oz. formula5 - 9T vegetable2 - 4T fruit

7 - 8 oz. formula1/2 dry toast or 2 crackers

7 - 8 oz. formula5 - 9T vegetable2 - 4T fruit2 - 5T baby cereal *

7 - 8 oz. formula **4 - 6T baby cereal *2 - 4T fruit

1/2 cup Vitamin C fortified fruit or juice1/2 dry toast or 2 crackers

7 - 8 oz. formula **1 - 2T meat5 - 9T vegetable2 - 4T fruit

7 - 8 oz. formula **1/2 dry toast or 2 crackers

7 - 8 oz. formula **5 - 9T vegetable2 - 4T fruit1T meat4T baby cereal *

6 - 8 oz. formula ** (1cup)1/4 - 1/2 baby cereal *2 - 4T fruit

1/2 cup Vitamin C fortified fruit or juice1/2 dry toast or 2 crackers

6 - 8 oz. formula ** (1 cup)2T meat2 - 6T potato, rice, noodles5 - 9T vegetable4 - 6T fruit

6 - 8 oz. formula ** (1 cup)1/2 dry toast or 2 crackers

6 - 8 oz. formula ** (1 cup)2T meat2 - 6T potato, rice, noodles2 - 4T vegetable2 - 4T fruit

May start sleeping through the night.

* If dry cereal is used, mix cereal and formula in a bowl. Feed with a spoon.** Formula may be offered in a training cup.

The facility or the mother must supply sterilized bottles or disposable nurser bags (see “Parent Agreement”).

The mother will store her milk in a bottle or bag and refrigerate or freeze the milk. The bottle or bag should contain no more than the amount of milk the child would drink at one feeding. The milk must be labeled with the child’s name and the date and time collected.

The bottles or disposable bags must be brought to the center in a clean, insulated container which keeps the milk at 41° F or below (see “Parent Agreement”).

Fresh, refrigerated breast milk must be used within forty-eight (48) hours of the time expressed. Frozen milk may be stored in a refrigerator freezer for three (3) to six (6) months or stored in a deep freezer at -4° F for six (6) to twelve (12) months.

Frozen breast milk may be thawed as follows:

NEVER HEAT BREAST MILK IN A MICROWAVE!

Note: Once a bottle is fed to infant, the remainder must be discarded and cannot be returned to the refrigerator.

Frozen breast milk may be thawed under warm water, gently swirled, used within one (1) hour or refrigerated immediately and used within twenty-four (24) hours. Label the bottle with the time and date thawed and method used for thawing (”warm water” or “heat thaw”).

Frozen breast milk may be thawed in the refrigerator at 41° F or below. Label the bottle with the time and date moved to the refrigerator and “cold thaw” method and use within twenty-four (24) hours. With this method, never warm the breast milk until ready to feed the child.

Do not refreeze the breast milk once it has been thawed.

(a)

(b)

(c)

Breast milk is a very special product. Provide a safe and excellent source of nutrition to your breast-fed infants by following the procedure below:

1.

2.

3.

4.

5.

PARENT AGREEMENT

I, _________________________________________, agree to provide my breast milk for my child ______________________________

in sterilized bottles or sterile nurser bags. I will store my milk in the appropriate serving size for my child. I take full responsibility for

maintaining this milk at 41° F or below during home storage and transport to the center.

Date (month, day, year)Signature of parent

BREAST MILK PROCEDUREState Form 49954 (R5 / 3-15)


INDIANAPOLIS, IN 46204

shalom daycare

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