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Run: Infant Safe Sleep Policy Acknowledgment Form

Use this Infant Safe Sleep Policy Acknowledgment Form to document parent/guardian and staff agreement on back-sleeping, crib safety, and any medical sleep in...

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Program and Acknowledgment Details

Program Name (required)

Policy Version or Effective Date (required)

Enter the policy version number or effective date shown on the safe sleep policy.

Acknowledgment Date (required)

Child Information

Child's Name (required)

Child's Date of Birth (required)

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 (required)

Relationship to Child (required)

I received and reviewed the infant safe sleep policy. (required)

This acknowledgment supports licensing compliance and records retention.

Yes No N/A

I understand that infants under 12 months must be placed on their backs for sleep unless a licensed medical provider has provided written instructions. (required)

Yes No N/A

I understand that sleep will occur only in a CPSC-compliant crib or approved sleep surface authorized by the program's policy. (required)

Yes No N/A

Does the child have a written medical sleep instruction? (required)

Upload Written Medical Sleep Instruction (required)

Shown only if a medical sleep instruction exists. Upload the provider's written instruction for the child's file.

Parent or Guardian Signature (required)

Staff Safe Sleep Attestation

Staff Name (required)

Staff Role (required)

I have completed safe sleep training required by the program or licensing rules. (required)

Yes No N/A

I will follow the infant safe sleep policy, including back-sleeping and approved sleep surfaces. (required)

Yes No N/A

Staff Signature (required)

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. (required)

Only the minimum necessary PII is collected for compliance and audit trail purposes.

Yes No N/A

I attest that the information provided is accurate and that I understand this form creates a compliance record. (required)

Yes No N/A

Additional Notes

Optional. Use only for brief policy-related notes; do not include sensitive health details unless necessary.

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