Alternate Sleep Position For Child Care Medical Waiver (For Infants Under 12 Months Of Age) printable pdf download

Alternate Sleep Position For Child Care Medical Waiver (For Infants Under 12 Months Of Age)

Alternate Sleep Position for Child Care

Medical Waiver

For infants under 12 months of age

Infants under 12 months of age are always placed on their backs to sleep, unless there is a

signed medical waiver on file. In that case, a waiver notice will be posted in a conspicuous

location on or at the infants crib that does not block the infant from the caregivers view. The

notice will only state the position the infant should sleep in and the date the waiver was signed.

The actual medical waiver should be placed in the infant’s file since it contains confidential

information.

Please complete all text boxes

Name of infant

Infants birthdate

Today’s date

Name of Primary Care Physician

Address of Primary Care Physician

Name of Practice

Phone

Fax

E-mail

Signature of Parent or Legal Guardian

TO BE COMPELTED BY INFANTS PRIMARY PHYSICIAN

The above named infant has the following health or medical condition that requires an alternate sleep position:

Describe the alternate position for the infant:

Additional instructions:

The above instructions are effective from

Date

(fill in boxes to the right)

Signature of Physician:

Date

Alternate Sleep Position For Child Care Medical Waiver (For Infants Under 12 Months Of Age)