Fill and Sign the Daycare or Child Care Agreement with Medical Treatment Authorization Form

Daycare or Child Care Agreement with Medical Treatment Authorization Agreement made on the _________________ (date), between ____________________ (Name of Owner of Daycare), D/B/A ______________________ (Name of Daycare) of ____________________________________________________________________________ (street address, city, county, state, zip code), referred to herein as Daycare, and _____________________ (Name of Parent) , of _____________________________________ _____________________________________ (street address, city, county, state, zip code), referred to herein as Parent.Whereas, ____________________ (Name of Owner) is the owner of a daycare service (Daycare) located at ___________________________________________________________ _________________ (street address, city, county, state, zip code) ; and Whereas, Parent desires to place his/her child ___________________ (Name of Child) in said Daycare pursuant to the terms of this Agreement; Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1. InformationA.Father or Legal Guardian 1. Name ________________________________ 2. Home Phone No. ______________________________________ 3. Work Phone No. _______________________________________4. Home Address ______________________________________________5. E-mail Address _______________________________________6. Employer’s Name and Address _________________________________ ________________________________________________________________ B.Mother 1.Name ___________________________________2. Home Phone No. ______________________________________ 3. Work Phone No. _______________________________________4. Home Address ______________________________________________5. E-mail Address _______________________________________6. Employer’s Name and Address _________________________________ ________________________________________________________________ C.Child 1.Name _____________________________________2. Date of Birth __________________________ 2.Basic Rates, Payment Policies and ScheduleA. The fees shall be:1. $______ per month;2. $______ per week;3. $______ per day; or 4. $______ per hour.B. Care shall be provided normally from _____ A.M. to _____ P.M. on the days (check which apply)._____ Monday  _____ Tuesday  _____ Wednesday  _____ Thursday  _____ Friday _____ Saturday _____ SundayC. Additional Fees 1. Registration fee $________________2. Bad check fee $________________3. Late payment fee $________________D. Payments shall be due on (e.g. the first day of each month) ________________________________________________. E.Overtime Rates1.For the purpose of this Agreement, overtime will be considered as drop- off before _____ A.M. _____ P.M., and pick-up after ____ A.M. ____ P.M.2. If Parent makes prior arrangements with Daycare, the child may stay overtime at the following rate: $_________ per __________ or portion thereof.3. If Parent has not informed Daycare that he or she will be arriving earlier or later than the agreed upon times, the following rate will be charged: $__________ per _____________ or portion thereof.FORM #1016F. Rates Regarding Holidays, Vacations, and Other Absences:1. The following are paid holidays when they fall on a day regularly scheduled for care: (designate holidays) _________________________ __________________________________________________________ __________________________________________________________2. Charges for a child’s absence will be: $_____________. 3. Charges related to illness or other emergency that prohibit care will be: $_____________ 4. Charges related to vacation of Parent will be $____________. Parent will give _______ weeks advanced notice of any scheduled vacation.G. Other Charges:There will be an extra charge for the following infant supplies when not provided by the Parent: (list supplies such as diapers, wipes, baby food, formula, etc.) ______________________________________________________________________ ______________________________________________________________________.3.Termination Procedure:This contract may be terminated by either Parent or Daycare giving written notice _____ weeks in advance of the termination date. Payment by Parent is due for the notice period, whether or not the child is brought to the Daycare. Daycare may terminate the contract without giving any notice if the Parent does not make payments when due. 4. Medical Treatment AuthorizationA. Parent hereby authorizes and voluntarily consents to having Daycare arrange, direct, sign for and consent to any and all routine or emergency medical care and treatment necessary to preserve the health of the child. Personal, insurance and health care provider information is set forth below.B. Parent acknowledges that he/she is responsible for all reasonable charges in connection with the care and treatment rendered and acknowledges that no guarantees have been made as to the effect of such treatment rendered.C.Child’s Personal Information1. Allergies: _________________________________________________ _________________________________________________________ 2.Medical Conditions:__________________________________________ ________________________________________________________________3.Social Security #: __________________________________________4. Insurance Information:Employer: _________________________________________________Member No.: _______________________________________Employee Social Security No.: _________________Administrator: ___________________________________________Group No.: ____________________________Confirmation Number: _____________________________ 5.Health Care Providers:Name of Pediatrician: _____________________________Phone Number: __________________________________Name of Dentist: __________________________________Phone Number: ___________________________________5.SeverabilityThe invalidity of any portion of this Agreement will not and shall not be deemed to affect the validity of any other provision. If any provision of this Agreement is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision. 6. No Waiver The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. 7. Governing Law This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of ________________. 8. Notices Any notice provided for or concerning this Agreement shall be in writing and shall be deemed sufficiently given when sent by certified or registered mail if sent to the respective address of each party as set forth at the beginning of this Agreement. 9. Mandatory Arbitration Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. 10. Entire Agreement This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. 11. Modification of Agreement Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party. 12. Assignment of Rights The rights of each party under this Agreement are personal to that party and may not be assigned or transferred to any other person, firm, corporation, or other entity without the prior, express, and written consent of the other party. WITNESS our signatures as of the day and date first above stated. ___________________________ Daycare Provider________________________ By_________________________ (Printed name) (Printed name) ________________________ ________________________(Signature of Parent) (Signature of Buyer)