Infant Safe Sleep Policy Acknowledgment Form

Captures parent/guardian and staff acknowledgment of infant safe sleep practices, including back-sleeping and CPSC-compliant crib requirements for children under 12 months, with a compliance attestation for state licensing records.

Program and Acknowledgment Details

• Program Name
• Policy Version or Effective Date
  Enter the policy version number or effective date shown on the safe sleep policy.
• Acknowledgment Date

Child Information

• Child's Name
• Child's Date of Birth
  Required to confirm the child is under 12 months for this acknowledgment.
• Child's Age in Months
  Optional calculated or recorded age for internal compliance use.

Parent or Guardian Acknowledgment

• Parent or Guardian Name
• Relationship to Child
• I received and reviewed the infant safe sleep policy.
  This acknowledgment supports licensing compliance and records retention.
• I understand that infants under 12 months must be placed on their backs for sleep unless a licensed medical provider has provided written instructions.
• I understand that sleep will occur only in a CPSC-compliant crib or approved sleep surface authorized by the program's policy.
• Does the child have a written medical sleep instruction?
• Upload Written Medical Sleep Instruction
  Shown only if a medical sleep instruction exists. Upload the provider's written instruction for the child's file.
• Parent or Guardian Signature

Staff Safe Sleep Attestation

• Staff Name
• Staff Role
• I have completed safe sleep training required by the program or licensing rules.
• I will follow the infant safe sleep policy, including back-sleeping and approved sleep surfaces.
• Staff Signature

Consent and Submission

• I consent to the collection and retention of the personal information provided in this form for licensing and child care recordkeeping purposes.
  Only the minimum necessary PII is collected for compliance and audit trail purposes.
• I attest that the information provided is accurate and that I understand this form creates a compliance record.
• Additional Notes
  Optional. Use only for brief policy-related notes; do not include sensitive health details unless necessary.