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Daycare or Child Care Agreement with Medical Treatment Authorization

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Daycare or Child Care Agreement with Medical Treatment Authorization

Agreement made on the , between , D/B/A of , referred to herein as Daycare, and , of , referred to herein as Parent.

Whereas, is the owner of a daycare service (Daycare) located at ; and

Whereas, Parent desires to place his/her 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. Information

A. 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 Schedule

A. 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

Sunday

C. Additional Fees

1. Registration fee $

2. Bad check fee $

3. Late payment fee $

D. Payments shall be due on .

E. Overtime Rates

1. 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.

F. 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 Authorization

A. 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 Information

1. 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. Severability

The 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)

________________________ ________________________

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What this Daycare or Child Care Agreement with Medical Treatment Authorization does

A Daycare or Child Care Agreement with Medical Treatment Authorization is a combined contract and consent form that establishes the terms of child care services and authorizes caregivers to obtain medical treatment for a minor when a parent or legal guardian cannot be reached. The form typically identifies parties, schedules, fees, emergency contacts, allergies and special medical needs, insurance information, and explicit medical treatment authorization language. It clarifies caregiver responsibilities, sharing of medical information, and procedures for emergency transport, while creating a record of parental consent for providers and medical personnel.

Why caregivers and parents use this combined agreement

Combining a child care contract with a medical treatment authorization reduces confusion during emergencies, documents expectations for care and payment, and provides legally useful written consent that medical providers and first responders can rely on when parents are unavailable.

Why caregivers and parents use this combined agreement

Who typically completes and signs this document

The form is usually completed by the enrolling parent or legal guardian and retained by the daycare, family child care provider, or camp operator prior to the child’s first day.

  • Parents or legal guardians — Provide identifying details, emergency contacts, insurance information, and grant specific authorization for medical care when unreachable.
  • Daycare directors and family providers — Use the agreement to document enrollment terms, care policies, and emergency procedures that staff must follow.
  • Designated emergency contacts or authorized pick-ups — Listed persons may be permitted to transport the child or provide consent per the authorization language.

Copies are kept with the child’s file, carried on field trips, and shared with designated emergency contacts and medical personnel as needed.

Primary signer roles and descriptions

Parent/Guardian

The parent or legal guardian named on the agreement signs to accept care terms and to grant permission for medical treatment if they cannot be reached; confirm identity and relationship to the child and include a daytime phone number and alternate contact methods.

Provider Representative

An authorized representative of the daycare signs to acknowledge receipt of parental instructions, to accept the responsibilities defined in the contract, and to confirm procedural steps for obtaining medical treatment or emergency transportation if required.

Key administrative and security elements to include

Child identity: Full legal name
Dates: DOB and effective date
Emergency contacts: Primary and alternates
Medical info: Allergies and conditions
Insurance details: Carrier and policy number
Authorization: Signed parental consent

Risks and potential consequences of incomplete or incorrect forms

Medical delay: Treatment may be delayed
Liability exposure: Provider or parent risk
Consent invalid: Missing signature voids authorization
Insurance denial: Claims may be rejected
Regulatory fines: Licensing citations possible
Care disruption: Child denied services temporarily

Common preparation and execution mistakes to avoid

  • Leaving signature or date fields blank, which can render medical authorization unenforceable when time-sensitive consent is required during an emergency.
  • Providing incomplete insurance or physician contact information, making it difficult for medical staff to verify coverage or obtain records quickly.
  • Using vague authorization language such as 'seek treatment as needed' instead of listing specific permitted actions, which can cause hesitation from providers.
  • Failing to update the form after custody changes, address moves, or new medical conditions, leaving the provider with outdated or conflicting instructions.

Step-by-step: completing the agreement accurately

Follow these steps to ensure the agreement is complete, clear, and legally useful for both caregiver and parent.

  • 01
    Gather documents: Collect child ID, insurance card, and physician contact information.
  • 02
    Enter child details: Type full legal name and MM/DD/YYYY date of birth.
  • 03
    List contacts: Provide at least two reachable emergency contacts with phone numbers.
  • 04
    Sign and date: Parent signs and dates in the signature block to grant authorization.

How authorization is used during an emergency

This sequence describes how staff, emergency responders, and medical providers rely on the signed authorization.

  • Incident occurs: Staff assess and stabilize the child on site.
  • Attempt contact: Provider calls parent and emergency contacts immediately.
  • Authorize treatment: If unreachable, staff present signed form to medical personnel.
  • Transport and care: Emergency transport proceeds with documented parental consent.

Essential sections to include in a professional agreement

A complete document balances contractual terms with clear, specific medical authorization language so caregivers and clinicians can act with confidence when time is critical.

Parties

Identify child, parent/guardian, and provider by full legal names and include legal relationship and contact details for each party to prevent ambiguity.

Medical authorization

State explicit consent language allowing treatment, hospital transport, and emergency procedures when the parent cannot be reached, and note any limitations or prohibitions.

Emergency contacts

List primary and alternate contacts with phone numbers and authorization level to consent or pick up the child in lieu of the parent.

Health details

Document allergies, chronic conditions, medications, and recent immunizations so medical staff have critical context for care decisions.

Insurance information

Record insurer name, policyholder name, policy or group number, and preferred physician to facilitate billing and records requests.

Terms and termination

Outline fee terms, cancellation notice, effective date, renewal and a process for updating or revoking the authorization to maintain current consent.

Practical tips for accurate and efficient completion

Implement these practices to reduce errors, speed processing, and maintain compliance with healthcare and child care rules.

Use clear printed text for paper forms
If completing a physical form, print legibly in block letters; illegible handwriting can delay treatment and cause information entry errors.
Keep copies with staff and on outings
Store a signed copy in the child’s file, carry one on field trips, and maintain an electronic copy in a secure system accessible by authorized staff.
Require annual updates
Request parents review and re-sign the form annually or when medical or contact information changes to ensure consent remains valid and current.
Confirm identity at pickup
Match photo ID to authorized pick-up names and check authorization language before releasing the child to someone other than the parent.

Timing and when you must collect or update the agreement

Collect signed agreements before the child’s first day and require updates when key information changes.

Before enrollment begins:

Obtain a signed agreement before admitting the child to ensure staff can act if needed.

Annual review required:

Ask parents to review and re-sign yearly or on program renewal.

After medical changes:

Require immediate updates when allergies, medications, or insurance details change.

Before special outings:

Carry a current consent on any field trip or off-site activity.

When custody changes:

Obtain revised authorization documents promptly after legal custody modifications.

Recommended digital workflow settings for online completion

Configure your online workflow to collect information reliably and preserve an audit trail for every signature and update.

Field Setting
Upload template Use a PDF or DOCX master with fillable fields
Signer roles Assign Parent and Provider roles with required fields
Authentication Use email plus SMS or access code for stronger identity verification
Storage Save signed copies to secure cloud storage and local backup

Technical considerations for eSigning and storage

Choose a platform that preserves an audit trail, supports PDF/DOCX, and meets basic privacy standards for health information.

  • Document formats: PDF and DOCX are universally supported
  • Integrations: Connect with Google Drive or Microsoft 365 for storage
  • Authentication: Enable email plus SMS or multi-factor options

Ensure your chosen vendor can produce tamper-evident signed copies, retain a verifiable audit trail, and meet any applicable privacy obligations.

eSignature pricing and capability snapshot for executing agreements

Compare common vendor entry pricing and select capabilities relevant to healthcare-sensitive child care forms; signNow appears first per vendor ordering rules.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card required Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes Yes
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap 100 envelopes/user/year No cap No cap No cap

Frequently asked questions about the agreement and authorization

Answers to common questions about validity, updates, electronic signing, and what to do during emergencies.


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