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):
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
click to sign
click to edit