Child’s name: DOB:
- I understand my permission is given for 1 year from the date signed and that I will need to provide permission on an annual basis while my child is in care at Country Fun Child Care.
- By initialing, I give permission for my child to use that piece of equipment listed below while under supervision at Country Fun Child Care.
Please initial before each piece of equipment to approve its use on the premises of (Business).
___ Balance/stepping logs surrounding dirt and chipped play area in backyard
___ Climbing structures on the playground (plastic and wooden with tube slide)
___ Dirt box under climbing structure in backyard
___ Half Bosu ball in the classroom
___ little tykes triangular climbing structure in the classroom
___ all riding equipment including but not limited to scooters and tricycles
___ Balancing Slackline between trees in backyard
___ Balance beams both inside in classroom and outdoors in yard area
___ Stackable, climbable large loose parts (wood, blocks, tires, rocks, etc)
Please initial before each high risk activity and its location off premises to approve its use.
___ Hiking neighborhood woods
___ Walking along North Street
___ Crossing Route 114 at Orchard Church and Phinney Lumber
_____ I do not give permission for my child to use the high risk equipment at (business name).
I understand I may revoke this permission in writing at any time for any reason.
Child’s Parent/Legal Guardian Signature: