Face Covering Agreement Form
For Children Ages Two Years Old to Kindergarten
Kindergarten is defined as children who have turned five by September 1 of the current
school year. This is the age a child is eligible to be enrolled in the public school system.
As the parent or guardian of ____________________________, I am requesting that my
(name and age of child)
child, while in your care, wears the face covering I have provided.
I understand the following:
It is my responsibility to provide a face covering that is properly
sized for my child.
The cover will fit over both the nose and mouth and will be
snug enough to stay secure without restricting my child’s breathing.
I understand that the face coverings I provide must be washed at home
with warm water and soap every day or after each use.
If I provide a single-use face covering it will be disposed of as soon as it is
damp and must be replaced daily.
If my child has a difficult time wearing the mask, is constantly touching,
removing or adjusting it, my child will not be forced to continue to wear it.
I understand that my child will not wear a face covering while eating,
drinking, resting or sleeping.
Please list any other times your child does not need to wear a mask while in child
care (e.g. outside):
Parent Signature
Based on definitions Oregon Administrative Rules Chapter 414 Division 205, Division 300, and Division 350
Oregon Department of Education • Early Learning Division • Office of Child Care • www.oregonearlylearning.com ECC-806 8/19/2020
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