Fill and Sign the Care Agreement Form

Sample Child Care Agreement The purpose of this agreement is to define the mutual terms for child care arrangements. Please let a member of our staff know of any changes of address, telephone or emergency numbers. Parents are welcome to visit at any time during child care hours.  Name of Child _____________________  Date of birth _____________________  Name(s) of Parent(s): _____________________ _____________________  Hours and Days of Operation  Child care services will begin on _____________________ (date). The hours for care will begin at _____________________ (time of day) and end at _____________________ (time of day) on the following days: _________________________________________ If your child is going to be absent or late, please call in advance. Child care will not be available on the following holidays: _______________________________________________________________ Fees $ _____________________ per week for full-time care. $ _____________________ per hour for regular, part-time care. $ _____________________ per hour for drop-in care, if space is available. $ _____________________ for late payment charged for any time after _____________________ (time) unless special arrangements have been made. Families are required to bring the appropriate foods for their children. Child care fees are payable in advance and are due no later than _________________ (time). Fees may be paid: Weekly Bi-weekly Monthly In advance deposit of $ _________ must be paid at the time of enrollment. This amount will be returned when services are terminated. Child care fees will be paid by: cash _________ check/M.O. _________ Notice: A two-week written notice is required for any of the following: 1. Termination of the agreement by either party. 2. Increases in child care fees. 3. Vacation periods for both families and provider. Information About Your Child Please help us know more about your child.  Language spoken at home: _____________________  How does your child communicate? _____________________  Favorite toys, playthings, or play interests: _____________________  Favorite foods: _________________________________________ _______________________________________________________________  Allergies, and/or food restrictions: _____________________ _______________________________________________________________  Medications taken regularly in case of emergency: _____________________ _______________________________________________________________ _______________________________________________________________ Please note: To reduce the risk of Sudden Infant Death Syndrome, your baby will be placed on his/her back to sleep (unless we receive a signed permission form stating otherwise from a licensed physician).  Blanket or special toy: _________________________________________  If your child attends school, please list:  School name _____________________  School phone number _____________________  Hours in school _________ a.m./p.m. to _________ a.m./p.m. Additional information which may be helpful in understanding your child, his or her needs, and in making the transition to this child care program easier: _______________________________________________________________ _______________________________________________________________ Please explain if the child has special dietary needs: _____________________ _______________________________________________________________  Infants will be fed according to family’s instructions. Please update and notify me of any changes in feeding schedules, formulas and additional foods. Breast-fed infants need to have an adequate supply of expressed milk in labeled bottles. Illness  Please notify us if your child will be absent because of illness.  If the child is absent, payment is still expected.  Please inform me of any contagious disease immediately.  If your child becomes ill during care, you will be asked to pick up your child within _____________________ (number) hours. If you cannot be reached, we will call one of the emergency numbers you have listed. Your child may return to child care when the child is no longer sick. Immunizations  Please provide a copy of updated immunization records each time your child has new immunization shots. Documentation of current immunizations is required in every child’s file. Clothing  Label your child’s clothing and other items with his/her name and bring it in some type of storage bag. Supply at least two complete sets of play clothes, outdoor clothing, and the following:  Diapers  Baby wipes  Bibs  Other Please provide a current photograph of your child in case it is needed in an emergency situation. I (We) fully understand and agree to the terms of this contract. This agreement may be re-negotiated at any time. Parent’s Signature __________________________ Date: _____________________ Parent’s Printed Name __________________________ Provider’s Signature __________________________ Date _____________________ Provider’s Printed Name __________________________