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No Shake Agreement

Print This for Anyone Who Comes in Contact with your Child

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:____________________________________
(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.

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