Permission to Use High-Risk Equipment

There has been a lot of questions raised on finding a balance on the use of play equipment that a child might be injured using, the language in the current Family Child Care Rule on climbing structures and impact surfaces, and what we understand around the importance of children having opportunities to develop risk awareness through their play. As providers we know there is a difference between risk and hazard. FCCAM has heard from members that they have addressed this by having conversations with client families and having an annual high-risk equipment form signed. Below is an example of such a form. (The equipment listed would be specific to the program.)


Permission to Use High-Risk Equipment

Child’s name:                                                                                    DOB:

◻ I understand my permission is given for 1 year from the date signed and that I will need to provide permission on an annual basis while my child is in care.

◻ I give permission for my child to use each of the initialed pieces of equipment listed below while under supervision at Country Fun Child Care.

Please initial before each piece of equipment to approve its use.

___  Balance/stepping logs surrounding dirt and chipped play area in backyard

___  Climbing structures on the playground (plastic and wooden with tube slide)

___  Dirt box under climbing structure in backyard

___  Half Bosu ball in the classroom

___  little tykes triangular climbing structure in the classroom

___  all riding equipment including but not limited to scooters and tricycles

___  Balancing Slackline between trees in backyard

___  Balance beams both inside in classroom and outdoors in yard area

___  Stackable, climbable large loose parts (wood, blocks, tires, rocks, etc)


◻ I understand I may revoke this permission in writing at any time for any reason.


◻ I do not give give permission for my child to use the high risk equipment at (business name).


Parent/Guardian Signature:



You can access this template to download and adapt to meet your program needs here.

If you do not have liability insurance, FCCAM encourages you to strongly consider securing that.