Infant Rolling Parent Statement DHS Form

Infant Rolling over Parent Statement for Infant Less Than Six Months Old

*Please Note: The use of this form for the parent's signed statement is optional*

An infant who independently rolls onto its stomach after being placed to sleep on its back may be allowed to remain sleeping on its stomach if the infant is at least six months of age or the license holder has a signed statement from the parent indicating that the infant regularly rolls over at home. Minnesota Statutes, section
Discovery Center Location Attending:*
Name of Infant*
Date of Birth of Infant (MM/DD/YYYY)*

MonthDayYear
Date
By completing this form, I (the parent) attest that my infant independently and regularly rolls over onto its stomach after being placed to sleep on its back. I (the parent) acknowledge that while in the care of the licensed program, my infant will be placed on its back to sleep and that when my infant independently rolls over onto its stomach while sleeping, the license holder may allow my infant to remain sleeping on its stomach.
Name of Parent or Legal Guardian*
Signature of Parent or Legal Guardian*

Clear
Date

MonthDayYear
Date
Name of Parent or Legal Guardian
Signature of Parent or Legal Guardian

Clear
Date

MonthDayYear
Date
Should be Empty: