Evening/overnight Care Agreement printable pdf download

Evening/Overnight Care Agreement

My child ___________________________ will be in the care of ________________________ during

(Name of child)

(Provider’s name)

_______________________

the evening or overnight hours. During this time, my child will nap on/in

(Mat/cot/porta-crib/bed)

_______________________.

___________.

and will be located in the

My child’s bedtime will be at

(Room in the home)

(Indicate time)

My child will be assisted with the following (check all that apply):

__________

Shower

__________

Tub Bath

__________

Sponge Bath

__________

Brushing Teeth

__________

Changing into Night Clothes

While sleeping, my child will be supervised in the following manner (check one):

My child care provider MAY use an electronic monitor if my child sleeps in a room where an

approved adult is not present. For overnight care, the provider may sleep while my child is

sleeping. The provider must remain on the same floor as my child at all times.

My child care provider MAY use an electronic monitor while my child sleeps, but must remain

awake and physically check on him/her every 15 minutes. The provider must remain on the

same floor as my child at all times.

My child care provider MAY NOT use an electronic monitor and must be awake and in direct

supervision of my child at all times. The provider must remain on the same floor as my child at

all times.

I am aware that if my child is an infant, he/she will be placed on his/her back to go to sleep to reduce the

risk of SIDS unless medical information is presented to the provider that shows that this arrangement is

inappropriate for that child (417.7(i)). In addition, I am aware that when night care is provided, a child

four years of age or older shall not sleep in a room shared with another child of the opposite sex and no

child three years of age or older shall sleep in the same room with an adult of the opposite sex (417.3(c)).

By signing this agreement and I am indicating I have read and understand the above guidelines. I will

report any changes to my child care provider and update this form as needed.

____________________________________________________

___________________

Parent Signature

Date

____________________________________________________

___________________

Provider Signature

Date

Developed by Child Development Council

Last Revised 5/2009

Evening/overnight Care Agreement

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