Infant Safe-Sleep Acknowledgment
Version 2026.1 · Effective August 23, 2026
Child
- Child’s full name: ______________________________________________
- Date of birth: ____________________
Standard sleep practices
Teida’s Tots will follow applicable safe-sleep requirements and written procedures, including:
- Using an approved individual sleep space for the infant.
- Placing the infant on the back for sleep unless an applicable written health authorization or care plan permits another position.
- Keeping the sleep space free of soft bedding and other prohibited items.
- Following required supervision and physical-check procedures.
Parent information
Parent instructions or information about the infant’s sleep routine:
__________________________________________________________________
__________________________________________________________________
☐ No additional sleep instructions at this time.
Conditional authorizations
☐ An alternate sleep-position authorization or healthcare-provider plan is attached.
☐ A swaddling authorization is attached, if applicable.
☐ No alternate sleep-position or swaddling authorization is requested.
Parent acknowledgment
I have reviewed the program’s safe-sleep practices and will provide current information about my child’s sleep needs. I understand that a separate written authorization or healthcare-provider plan is required for any applicable exception.
- Parent/guardian signature: ______________________________________
- Printed name: _________________________________________________
- Date: ____________________
Annual/update review
- Last reviewed: ____________________
- Parent initials: __________________
- Provider initials: ________________
Required healthcare-provider plan attachments, when applicable
- Current healthcare-provider asthma care plan, if applicable.
- Current healthcare-provider seizure care plan, if applicable.
Parents must provide the current applicable healthcare-provider or Department-approved plan. This packet does not replace those plans.