Permission to Use High-Risk Equipment

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:

Date: