Parent/Guardian Notice of No Liability
Insurance and Acknowledgment
(Only Complete this Form if Instructed by your Child Care Provider)
I understand I am being informed in writing by signing this
acknowledgment that this child care facility does not carry
liability insurance sufficient to protect my children in the event of
an injury, etc.
Parents’/Guardians’ Signature(s):
Date:
Date:
Printed Name(s):
Per SB 24 (2004) requiring child care facility owners who are not covered by liability
insurance to provide and retain written notice regarding no coverage to the parents and
guardians.
LITTLE HEAVENLY ONES DAYCARE
PROVIDER :