Family Child Care Sample Forms Packet Page 6
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12Outdoor Play with Periodic Supervision
This form can only be used only for children five (5) years of age or older if the outdoor play space
is enclosed by a fence at least four (4) feet high and located on the child care premises of a single
family or first floor residence.
I hereby give ____________________________________________ permission to allow my
(Educator/s)
child _______________________________________ who is __________________________ years
old to play outside, in a four (4) foot high fenced in outdoor play space on the family child care
premises, without the Educator(s) being outside with him/her. I understand that the Educator(s). must
check on my child every fifteen (15) minutes and the time outside alone cannot exceed one (1) hour.
___________________________________
____________________________
Parent’s/Guardian’s Signature
Date
Page 6 of 12
FCCSampleFormPacket20100203
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