FACILITY OR CAREGIVER'S NAME:_________________________ CHILDREN'S NAMES: ____________________________ ____________________________ ____________________________ This is to confirm that the parent or guardian of the above-listed children has been notified that the following animals are on the premises of the child care facility and may be present around children in care: _________________________ _______________________ _________________________ _______________________ I will not shut my animals up in a room. They will be allowed to roam freely as they do when children are not here. However, they will NOT be allowed in the kitchen or dining room during meal preparations or around children during napping hours. ___________________________________ Signature of Parent/Guardian Date ___________________________________ Signature of Provider Date
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