Optional Form for Parent Statement: Infant Less Than Six Months of Age Regularly Rolling Over

Optional Form for Parent Statement: Infant Less Than Six Months of Age Regularly Rolling Over
An infant who independently rolls onto their stomach after being placed to sleep on their back may be allowed to remain sleeping on their stomach if the infant is at least six months of age or the license holder has a signed statement from the parent or legal guardian indicating that the infant regularly rolls over at home. Minnesota Statutes, section 245A.1435
Site Location:*
Infant’s name*
Infant’s date of birth (MM/DD/YYYY)

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

Clear
Date*

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Date
Parent or legal guardian name
Parent or legal guardian signature:
Date

Clear
Date

MonthDayYear
Date
**Please note: Documentation is required in order to allow an infant under six months to remain sleeping on their stomach after rolling over. The use of this form is optional to satisfy the documentation requirement.**
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