Diaper Consent Form
Diaper Consent Form CityGate Church Kids Ministry I (parent/guardian)|__________________________________| give my permission for the staff of Kidz Towne, the children’s ministry of the CityGate Church, located at 1125 Towne Street, Cincinnati, OH 45216 to diaper change and/or assist my child with toileting (child’s name)|__________________________________|when needed. I understand that my supplies (i.e. diapers, wipes, diaper cream etc.) will be used as directed on my child and that diaper changing/toileting will be done according to the child’s needs. I also understand that my child’s diaper will be changed quickly as possible if it becomes soiled. In order to provide your child with the utmost comfort, their diaper changing/toileting will be checked hourly. If your child shows any signs of redness etc. You will be notified at check-out. We will not use anything such as cream on your child unless you provide them and give instruction on its use.
Please check the below statements if you agree: |___| I understand the above stated policy and give my permission for my child to be assisted in the bathroom if necessary. |___| I understand the above policy and give my permission for the Kidz Towne staff to change my child’s diapers. |___| I DO NOT give my permission for Kidz Towne staff to diaper change/provide toileting assistance to my child. I understand that in the event that my assistance is needed with diaper changing/toileting, I will be called out of service and it is my responsibility to tend my child. Additional Information: |__________________________________________________| |______________________________________________________________________| |______________________________________________________________________|
|______________________________________________| SIGNATURE OF GUARDIAN
|_______| / |_______| / |___________| DATE
Please check the below statements if you agree: |___| I understand the above stated policy and give my permission for my child to be assisted in the bathroom if necessary. |___| I understand the above policy and give my permission for the Kidz Towne staff to change my child’s diapers. |___| I DO NOT give my permission for Kidz Towne staff to diaper change/provide toileting assistance to my child. I understand that in the event that my assistance is needed with diaper changing/toileting, I will be called out of service and it is my responsibility to tend my child. Additional Information: |__________________________________________________| |______________________________________________________________________| |______________________________________________________________________|
|______________________________________________| SIGNATURE OF GUARDIAN
|_______| / |_______| / |___________| DATE
