Please enable JavaScript in your browser to complete this form. - Step 1 of 5Parent Directive for infant safe sleep positionChild's Name *Birth DateAgeInfantOne (1) Year OldPride Academy recommends back sleeping for all babies. At Pride Academy we must place an infant in a crib to sleep directly on a firm mattress and must position the infant on his/her back to sleep unless there is a signed directive from a parent or legal guardian for an alternate sleep position. Car seats, swings, couches, rockers or on the floor are not acceptable as an alternative sleep position. Pride Academy uses a fitted crib sheet that fits tightly on the mattress and overlaps the mattress so it cannot by dislodged by pulling on the corner of the sheet. Pride Academy also only uses cribs that meet specific requirements specified In regulations and cribs are checked monthly to assure that they are safe. These requirements apply to all license holders that serve infants up to and including twelve months of age. Babies sleep safest on their backs. One of the easiest ways to lower a baby's risk of Sudden Infant Death Syndrome (SIDS) is to put him/her back to sleep for naps and at night Since the recommendation to place a baby on his/her back for sleep began, the SIDS rate In the United States has dropped by more than fifty percent Placing babies on their back to sleep Is the number one way to reduce the risk of SIDS. The following are recommendations for safe sleep for your baby: 1. Your baby should always be put on his/her back to sleep. The back sleep position Is safest and every sleep time counts. 2. Your baby should be put to sleep on a firm sleep surface, such as a safety-approved crib mattress covered by a fitted sheet Never place a baby to sleep on a pillow, quilt, fluffy blanket or other soft surfaces. 3. Keep soft objects, toys and loose bedding outside of the baby's sleep area. Do not use pillows, blankets or quilts.Name of Parent/Guardian: *Date Directive for Alternate Sleep Position: By signing below I acknowledge that I have read the information regarding Safe Sleep and that I am directing my provider to always: CheckboxesPlace my baby on his/her stomach for sleep periods (not recommended)Place my baby in an altermlte position for sleep periods (not recommended)List alternate position belowAlternate PositionName of Parent/Guardian: *Date safe Layout Food NextAll About Me!Infants Information Sheet Infant room or 1 year old (Choose One)Infant room1 year oldName *Birth DatePhoneAgeAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMy current medical conditions are: My current food allergies:My Sleep TimesWakeupDally Nap BedtimeTo help me relax and go to sleep, I enjoy:My Meal TimesBreakfastSnackLunchSnackChoose OneI am breast fedI am bottle fedI drink from a Sippy cupDinnerType of formula:Special instructions for preparing my formula: I enjoy eating: The following items must be provided on the child's first day of attendance: food formula water diapers and wipes Must be in original unopened store bought packaging. Please provide an extra weather appropriate change of clothing. Thank you. NextINSTRUCTIONS: Prior to admissions, a feeding plan shall be established and written for each Infant (age six (6) 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 BirthAge in MonthsTime to FeedFormula Food Item/AmountSpecial InstructionsSignature/Name of Parent or Medical ProviderDateAge in MonthsTime to FeedFormula Food Item/AmountSpecial InstructionsSignature/Name of Parent or Medical Provider DateSignature/Name of MD, DO, NP, PA *DateNextNextItems Needed - Infants All items entering the facility cannot be open...MUST be brand new in original store packaging.Unopened items include: • 2 Baby Bottles • Baby Pacifier • 4 Extra Clothing (Pants, shirts, socks) • Diapers • Wipes • FAMILY PICTURESubmit