Sample Permission Forms for Home-Based Child Care Providers:
    Transportation, Field Trips, Insect Repellant, Baby Powder, Medical Release, etc.

These are the forms that we use to get permission from parents for various activities and needs. The forms were developed for use in Minneapolis, Minnesota, and we made an effort to conform to the state licensing rules of Minnesota.

Important Note:  we assume no responsibility for your use of these or similar forms. These forms have NOT been reviewed by an attorney or child care licensing agency. We revise our forms as needed. Use at your own risk!

We have used parent permission forms for many years. We feel they serve several important functions.

  1. Education:  the parent's know what we do with their children, and have some idea how we do it.
  2. Liability:  with parent permission, we feel somewhat more protected if something goes wrong.
  3. Licensing:  licensing authorities may require or prefer that we have written permission for activities or procedures.
Note:  You may copy these files into your own word processor or publishing software and format it to look better. Use only the parts that work for your child care home. We often revise our forms, and encourage you to do the same.


General Transportation & Field Trip Permission Form, Long Term  (Sample Form - Use at Own Risk)

As parent or guardian of ______________________________________________________ ,  I give permission to Turner & Kauper Child Care for the following selected transportation and field trips.
>>>  Please initial each item you agree to.

___   Walks, in the neighborhood, parks, lakes, the river, with Michael, Marian, an employee, or parent.

___   Trips in the day care van or car. Children always use a car seat or seat belt. Such trips are frequent.

___   Trips in a van or car belonging to a trusted volunteer (usually a parent) or employee. Children always use a car seat or seat belt. Such trips will be closely supervised.

___   I give permission for my school-age child to ride in the front passenger seat of a car or van. If the vehicle has an air bag, it will be a later model, dual velocity unit.  Children will always use a lap and shoulder belt.

___   I give permission for my child to ride on public transportation with the day care. Specifically, this includes city buses, the Lake Harriet Trolley, and similar vehicles.

___   I give permission for my child to go horse back riding at Sue Lavenz’s horse farm. Horses can be dangerous. Children ride full-size horses and ponies. Riding will be closely supervised. Sue Lavenz is an expert riding instructor. We have taken children to her farm several dozen times.

___  I give permission for my child to attend the Minnesota State Fair. We will eat Fair food, view animals, and go on Midway and Kidway Rides, such as the Ferris Wheel and the bumper boats.

___   I give permission for my child to go canoeing with an adult who can swim. The children always wear approved, self-righting life preservers. The canoe is equipped with internal flotation devices.

>>>  All parents and guardians must sign.
 

_____________________________________          ________________________________________
   (Signature)                                  (Date)                            (Signature)                                           (Date)



*** Permission for Medical Treatment ***    (Sample Form - Use at Own Risk)
To be presented to medical personnel in case
of emergency involving a child in day care.

   My child(ren) _______________________________________ is (are) enrolled in the licensed family child care home of Marian Turner & Michael Kauper, the Turner & Kauper Child Care.

   By signing this form I give permission to qualified medical personnel to provide medical treatment to my child(ren) while in the care of Turner & Kauper or their employees, but only in case I cannot be contacted to give permission personally, or I am otherwise unavailable.

   Until I can be contacted or become available, please cooperate with Turner & Kauper in providing medical care as they see fit.

   Please provide care and treatment to minimize unnecessary pain, complications, scarring, or delays in recovery, as well as to protect life and limb.

   Turner & Kauper Child Care has medical and liability insurance through the Adults and Childrens Alliance.

Known allergies to antibiotics or medicines:
_____________________________________________________________________________

I do not give permission for the following treatments: _________________________________    _____________________________________________________________________________
__________________________________________________    __ Check here for no exclusions.

My preferred physician, when available, is ___________________________________________
My preferred clinic or treatment facility is ___________________________________________
My medical insurance is _________________________________________________________

Special instructions and comments _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Phone numbers where I might be reached:  Home: ____________________________________
Work: ________________________________ Cell: __________________________________
Other: _______________________________________________________________________

_____________________________    ___________________________    _________________
(Signature, parent or guardian)             (Printed name)                                  (Date)

_____________________________    ___________________________    _________________
(Signature, parent or guardian)             (Printed name)                                  (Date)

rev. 1.3, Oct. 27, 2002



Permission to Apply Lotions,  Ointments, and Powders   (Sample Form - Use at Own Risk)

As parent or guardian of _________________________________________, I give Turner & Kauper Child Care permission to apply the following selected protective or medicinal materials.

>>> Please initial the items you agree to. All parents and guardians must sign at the bottom.

___  Sunscreen as needed, applied liberally, for outdoor play, field trips, and especially for swimming or canoeing. We use sunscreen often, but not 100% of the time.

___  Insect repellent, applied sparingly, only when necessary. We use a moderate strength repellent, such as Off Skintastic®. We often apply more repellent to clothing than to skin. We use insect repellent rarely, but we prefer to have permission to use it when needed.

___  Diapering powder, for comfort, and to prevent or treat diaper rash. We use diaper powder often; the babies and toddlers like it.

___  Diapering ointment, such as zinc oxide or A&D®, to prevent or treat diaper rash. We apply ointment occasionally.

___  Antiseptic cream or ointment, such as Bacitracin®, for minor cuts and abrasions, to prevent infection, and to sooth or ease pain.

___  Topical analgesic, such as Skeeter Stick®, to ease pain or itching from an insect sting or bite.

___  Petroleum jelly or hand cream, to prevent and treat dry skin on hands or face.
 
 

_____________________________________     __________________________________________
    (Signature)                             (Date)                  (Signature)                                          (Date)


Even with parent permission the child care provider is still responsible for the safety and well being of the children and for following the licensing rule.

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