Privacy Permission Agreement

My first priority is to protect your childs health and safety. To ensure that I am
operating with your full understanding and agreement about your familys privacy, I ask
that you grant me permission to conduct the following activities. Please initial each item to
which you give your consent and sign below.

_____ Taking and developing photos of your child(ren)

_____ Placing photos of your child(ren) around my home.
_____ Giving copies of photos your child(ren) is/are depicted in to other families in my
care.
_____ Placing photos of your child in a photo book for viewing by prospective families and
other families in my care.
_____ Posting artwork and other crafts that include your child(ren)s name around my
home.
_____ Occasionally involving neighborhood children in activities with the children in my
care.
_____ Using an electronic monitor to listen to your child(ren) from another room.
_____ Listing the name of your child(ren) or other member of your family in artwork or
bulletin boards.
_____ Using photos of your child, listing his or her name in videos or photo books given to
all families with pictures of their children depicted in the video or photo book.

_______________________________________________________
Parent or legal Guardian Signature

Date

_______________________________________________________
Parent or legal Guardian Signature

Date