MN DHS Swaddling Consent for an Infant

MN DHS Swaddling Consent for an Infant
Placing a swaddled infant down to sleep in a licensed setting is not recommended for an infant of any age* and is prohibited for any infant who has begun to roll over independently.

However, with written consent of a parent or guardian, a license holder may place the infant who has NOT YET BEGUN to ROLL OVER ON ITS OWN down to sleep in a crib, on their back, in a one-piece sleeper equipped with an attached system that fastens securely ONLY across the upper torso, with no constriction of the hips or legs, to create a swaddle.

Any other type of swaddle, including with a blanket, is prohibited.

Prior to any use of swaddling for sleep by a licensed provider, the license holder must obtain informed written consent for the use of swaddling from the parent or guardian of the infant. The parent or guardian must demonstrate to the provider how to safely place baby in the swaddle so it is not too tight or too loose.

I give Little Stars the permisison to: place my infant to sleep in a crib, on their back, in a one-piece sleeper equipped with an attached system (“wings”) that fastens securely ONLY across the upper torso to create a swaddle.
Child Name*

First NameLast Name
Child Date of Birth*

MonthDayYear
Date
Program Name
Select all that apply*

I verify that my infant has NOT yet begun to roll over.I verify that the provider will only use the one-piece sleeper to swaddle my infantI verify that the provider has a one-piece sleeper with attached “wings”I verify that I have provided the one-piece sleeper with attached “wings”I verify that I have demonstrated to the provider how to place baby in the swaddle.I verify that I will immediately notify the provider when my infant has begun to roll over.
At the time that the parent or provider observes that this infant has begun to roll over, this parental consent is no longer valid.
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*

Clear
Date of Signature

MonthDayYear
Date
I have clicked "Preview PDF" and reviewed my form for accuracy*

YesNo
Please verify that you are human*
Should be Empty:

MN DHS Swaddling Consent for an Infant

Signatures