Child Care Agreement Form

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Child Care Agreement
I, _________________________________________________________, the legal guardian of
_________________________________________agree to the following:
(Initial all that apply)
__________Pay fee per day/per week of _____________.
__________Day payment to be made is _____________________.
__________Volunteer to work _____________________ hours a week with the program.
__________ Follow the procedures in the program handbook.
__________Obtain a Special Care Plan, if applicable.
__________Services to be provided as part of the child care fee (transportation, meals, etc.)
are:_____________________________________________________________________________
________________________________________________________________________________
__________Child’s arrival time _________________Child’s departure time________________.
__________ Pay a late fee of, when applicable $ ___________________________.
__________ Obtain and provide records of health assessments/immunizations for my child according
to the schedule recommended by the American Academy of Pediatrics.
__________Cooperate with_____________________________in the follow-up of any medical,
dental, and/or developmental needs of my child.
__________Notify the staff when my child is ill or any family member has a reportable contagious
disease.
__________Complete a medication consent form when requesting medication administration by child
care staff.
__________Provide the program staff with ________________________________necessary for my
child’s care. (linens, clothing, toothbrush)
__________Provide information on how to contact me in an emergency situation, which I will update
every 6 months at a minimum and when changes occur.
__________Agree to discuss my concerns with __________________________________.
(staff member’s name)
__________Notify a teacher and sign my child in and out every time my child arrives and departs with
me or an authorized person.
Child Care Agreement
I, _________________________________________________________, the legal guardian of
_________________________________________agree to the following:
(Initial all that apply)
__________Pay fee per day/per week of _____________.
__________Day payment to be made is _____________________.
__________Volunteer to work _____________________ hours a week with the program.
__________ Follow the procedures in the program handbook.
__________Obtain a Special Care Plan, if applicable.
__________Services to be provided as part of the child care fee (transportation, meals, etc.)
are:_____________________________________________________________________________
________________________________________________________________________________
__________Child’s arrival time _________________Child’s departure time________________.
__________ Pay a late fee of, when applicable $ ___________________________.
__________ Obtain and provide records of health assessments/immunizations for my child according
to the schedule recommended by the American Academy of Pediatrics.
__________Cooperate with_____________________________in the follow-up of any medical,
dental, and/or developmental needs of my child.
__________Notify the staff when my child is ill or any family member has a reportable contagious
disease.
__________Complete a medication consent form when requesting medication administration by child
care staff.
__________Provide the program staff with ________________________________necessary for my
child’s care. (linens, clothing, toothbrush)
__________Provide information on how to contact me in an emergency situation, which I will update
every 6 months at a minimum and when changes occur.
__________Agree to discuss my concerns with __________________________________.
(staff member’s name)
__________Notify a teacher and sign my child in and out every time my child arrives and departs with
me or an authorized person.
The following are the designated individuals who are authorized to pick up my child:
1. Name:_______________________________________Relationship:____________
Address:_________________________________________________________________________
Work/home phone number: _________________________Cell phone:______________________
2. Name:_______________________________________________Relationship:____________
Address:_________________________________________________________________________
Home/ Work phone number: __________________________Cell phone:______________________
Legal Guardian
Signature:__________________________________Date:__________________________
Staff Signature _____________________________Date:____________________________
This agreement should be reviewed by the legal counsel for your facility. Contracts usually include
more information than present on this form.
th
Adaptation of form -American Academy of Pediatrics (2002) Model Child Care Health Policies, 4
Ed.

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