Child Care Activity Authorization Form printable pdf download

Child Care Activity Authorization Form

Y/N

____ I give permission for my child,___________________________ , to walk to and/or participate

in activities geared for my child, but away from the child care residence under the supervision

of my provider or adult helper. My provider will inform me in advance of field trips beyond

the immediate neighborhood.

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____ I give permission for my school-age child,______________________________ ,

date of birth: ______________, to walk unsupervised to: ____________________ ,

the bus stop at___________________________________.

(Location)

The school my child attends is:_____________________________________________.

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____ I give permission for my school-age child, _____________________________, age________,

to be off or away from my child care provider’s premises, to participate in:

________________________________________________. I understand that my child will

not be under the direct supervision of the child care provider, substitute, or helper.

Restrictions:__________________________________________________________________

____________________________________________________________________________`

____________________________________________________________________________

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____ I give permission to_________________________ to transport my child(ren) in his/her vehicle

for the following reasons:

_____Trips to the library

_____Trips to the bus stop/elementary school

_____Trips to preschool

_____Other __________________________

_____Trips to the park/playground

_____Other __________________________

All child(ren) will be fastened in a safety seat, seat belt, or harness appropriate to their weight

and the restraint must be installed and used in accordance with the manufacturer’s instructions

and state law.

Parent or Guardian Signature: _______________________________________ Date: ____________

Provider Signature: _______________________________________ Date: ____________

Child Care Activity Authorization Form