Water Activity Permission Form

This form may assist child care operations in meeting the water safety requirements in Chapter 341 of the Health and Safety Code, section 341.0646.

Directions: The day care provider gives this form to the child's parent or guardian. The parent or guardian completes the form in its entirety and returns it to the day care provider before the child participates in water activities. The day care provider keeps the form on file at the child care facility and has the parent or guardian update the form annually.

Igive consent for my child to participate in the following water activities: (Check all that apply) Water Table Play Sprinkler Play Splash Pad Wading pool Water Park or Aquatic Playground Swimming Pool (at or away from the operation)

My child can swim without assistance:YesNo

My child's swimming abilities: (Check all that apply)

Please place a properly fitted and fastened US Coast Guard approved life jacket on my child before entering any swimming pool or water park area and require it to be left on at all times while in or around water. I will provide a Type 1, 2, or 3 US Coast Guard approved life jacket for my child. Please provide my child with a Type 1, 2, or 3 US Coast Guard approved life jacket. A competent swimmer (has successfully completed swimming lessons) My child CAN enter and exit a pool safely on their own. My child CAN tread water or float on their back for 1 minute. My child CAN swim 25 yards with no assistance.

htps://www.redcross.org/get-help/how-to-prepare-for-emergencies/types-of-emergencies/water-safety.html https://drowningispreventable.org/