This authorization form grants permission for a child named [CHILD'S NAME] to participate in various indoor and outdoor activities at the Alif-Ba-Ta Learning Center, allows for the application of sunscreen and over-the-counter medications, and gives the provider authorization to seek emergency medical care. The parents must initial lines to approve or deny activities like TV, videos, gaming, and telephone use. The form requires annual notarization to provide emergency medical authorization for the childcare provider.

1. Authorization and Permission Form for _______________________ (child’s name)
I/We _____________________________________________, hereby grant permission to Yasmeen Nasira ofAlif-Ba-Ta Learning Center to provide
the following activities for our child by initialing & signing below.
1. I/We hereby grant permission for our child to use all of the indoor and outdoor play equipment and to participate in all of the activities
of this childcare home. ______
2. I/We hereby grant permission for our child to sleep in a nap room on a bed, playpen, mat or cot provided. ______
3. I/We hereby give permission for our child to leave the childcare premises under the supervision of a responsible adult for neighborhood
walks and other scheduled and unscheduled excursions. Permission forms for each trip are not required.______
4. I/We understand that all field trip expenses are the parent’s responsibility and agree to this as it is stated in the policy statement of this
child care home. I/We also understand that if a field trip will take place that the provider will give advance notice and a separate
permission form to be signed with the details of the trip. I also understand that if I choose for my child not to attend, that it is my
responsibility to find alternate care for that day without childcare reimbursement from the provider for the fieldtrip.______
5. I/We give permission for our child to have sunscreen applied on exposed skin areas before going outside on sunny days. Sunscreen is
supplied by the parent/provider and applied per stated in the health policies handbook. ______
6. I/We give permission for over the counter products and topical to be used on our child for preventative purposes including but not
limited to skin lotion, diaper cream/ointments, Orajel, Neosporin, Chapstick, or ___________ and ______________.
7. I/We GIVE/DO NOT GIVE(circle one) permission to introduce new foods to my child before the age of 12 months. Parents will keep the
provider informed of the foods being introduced. ______
8. I/We give permission to work on potty-training my child once they are determined ready for this process. I understand that a child seat
will be used on a regular toilet if needed. ______
11. Initial to Initial to I/We give permission for my child to participate in each of the following activities for no more than 2 hours
Approve Deny each day. All media programs contain age-appropriate content (G or PG ratings) and will not contain
violence, profanity or other inappropriate content.
A Television
B Video
C Gaming systems
D Computer
E Music & Movement
F Telephone (real) for the purpose of:
I/We _______________________________________________, authorize Yasmeen Nasira of Alif-Ba-Ta Learning Center to call a doctor, 911, or an
ambulance for medical or surgical care for my/our child __________________________________ (child’s name), should an emergency arise. It is
understood that a conscientious effort will be made to locate the parents/guardians before emergency action will be taken, but if this is not
possible, the expenses of emergency medical treatment or care will be accepted by the parents/guardians. Notarization is required annually to
provide the childcare provider with authorization to give medical authorization to emergency/health professionals:
_______________________________________ _____________________
Parent/Guardian Date
_______________________________________ _____________________
Parent/Guardian Date
Subscribed and affirmed before me this ____________ day of ___________, 20__, in the County of __________________________, State of
Colorado.
______________________________________
Notary Public
My Commission Expires: _____________________________