ITS-SID Alternative Sleep Position Parent Waiver Parents may only use this waiver for infants over the age of 6 months. Child's Name * First Name Last Name Date of Birth MM DD YYYY Age in months Parent / Guardian Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent Phone (###) ### #### Email The child care facility named below places all infants on their backs to sleep to reduce the risk of Sudden Infant Death Syndrome (SIDS). As the parent or guardian of the child named above I request that the child be placed to sleep in an alternative sleep position now that my child is 6 months or older. The facility shall retain the waiver in the child's record as long as the child is enrolled at the center. This waiver is valid if I sign below. I request that my child not be placed on the back to sleep and instead placed to sleep in the alternative sleep position described below. TYPE PARENT NAME HERE. I request that the child care facility place my child in the alternative sleep position described below. Effective Dates From What Date and To What Date I, as the parent orguardian oft h e above mentioned child, do hereby release and hold harmless the child care facility listed below, its officers, directors, and employees, from any and all liability whatsoever associated with harm to my child due to SuddenInfant Death Syndrome (SIDS). Iaffirm and acknowledge that the child care facility named abovegave meinformation about SIDS. Iauthorize thischild care facility and its employees to placemy child in the alternative sleep position described above at my request. TYPE PARENT'S NAME & DATE AUTHORIZED FACILITY REPRESENTATIVE An authorized facility representative of the child care facility completes this section. Name of Child Care Facility ID# Facility Representative Name & Date Thank you!
