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No Shake Agreement

Print This for Anyone Who Comes in Contact with your Child


Prevention begins with education.
The Shaken Baby Alliance and Robyn's Nest ~ The Parenting Network are dedicated in part to educating parents and
caregivers about the dangers of shaking a baby.
We encourage you to print the following pages and attach them to this form to document your child care provider's education on the issue of Shaken Baby Syndrome and its tragic consequences. In addition, we encourage child care providers to print out these pages and give them to their parents.


I, ________________________________(your name), have
received copies of shaking dangers, signs/symptoms, coping
with a crying baby, and crisis hotlines information.

I have read this information and understand that I should
NEVER shake a baby and that shaking can result in learning
and behavioral problems, blindness, seizures, paralysis,
cerebral palsy, hearing loss, speech difficulties, mental
retardation, and death.

Signed by:________________________________
(Signature of Person Receiving Information)

(Date Information Received)

Parents, child care providers, and other caregivers, please keep a copy of this written acknowledgement of receipt of shaken baby syndrome information for your own files. This information should be given to your local law enforcement or prosecutor in the event a child is diagnosed with SBS.

©1999, The Shaken Baby Alliance
P.O. Box 150734, Ft. Worth, TX 76108
(877) 6-END-SBS; (877) 636-3727

Related Topics
Shaken Baby Syndrome
SBS and Child Abuse Resources
25 Alternatives to Shaking a Baby
Colic and Crying (Why Babies Cry)

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Robyn's Nest ~ The Parenting Network
No Shake Agreement