Prevention of Shaken Baby Syndrome and Abuse Head Trauma Policy

Prevention of Shaken Baby Syndrome & Abusive Head Trauma

Parent or guardian policy acknowledgement
I, the parent or guardian of
Child's Name*

First NameLast Name
acknowledges that I have read and received a copy of the facility's Shaken Baby Syndrome/Abusive Head Trauma Policy.
Date policy given/explained to parent/guardian

MonthDayYear
Date
Date of child's enrollment

MonthDayYear
Date
Parent / Guardian Name:

First NameLast Name
Parent / Guardian Signature:

Clear
Date

MonthDayYear
Date
Should be Empty: