The following agreement is made between:
1. Mother/Legal Guardian_____________________________ Home Phone______________________
Work Phone____________________ Cell Phone _____________________
Home Address _________________________________________________________________________
Employer's Name & Address______________________________________________________________
and/or
2. Father/Legal Guardian_______________________________ Home Phone ________________________
Work Phone____________________ Cell Phone _______________________
Employer's Name & Address______________________________________________________________
and
3. Diana Davidson - Childcare Provider
4. First Child's Name & Date of Birth ______________________________
Second Child's Name & Date of Birth _____________________________
5. Schedule: Care shall normally be provided from _______ to ______ on these days - (Circle all that apply)
Monday Tuesday Wednesday Thursday Friday
Rate shall be _________ per ________
Anticipated Start Date________________________
6. Physician, or hospital to be called in case of an emergency when parent cannot be reached
_____________________________ Phone __________________________
7. Additional persons authorized to be called when a parent cannot be reached and who may pick up child if a parent is unavailable.
Name_____________________________ Home Phone __________________________
Work Phone _______________________ Cell Phone _____________________________
Relationship to child___________________________________
* * * * * * * * * * * * * * *
Name_____________________________ Home Phone __________________________
Work Phone _______________________ Cell Phone _____________________________
Relationship to child___________________________________
* * * * * * * * * * * * * * * Name_____________________________ Home Phone __________________________
Work Phone _______________________ Cell Phone _____________________________
Relationship to child___________________________________
* * * * * * * * * * * * * * *
8. Any food Allergies or other food information__________________________________________________
9. Other issues of concern or any special needs of the child _______________________________________________
________________________________________________________________________________________________
10. Admission Requirements
A copy of shot records, all enrollment forms including signed Contract, Policy Agreement, Trip Permission Slip, Medical Consent form (notarized), Facility Statement, Emergency Safety Plan, Permission to Release Information, Photo Permission form, and Copies of Drivers License must be on file BEFORE child can attend daycare.
Health Statement must be on file within 30 days of start date.
A medication release form must be signed by physician if provider is to administer any medication including over the counter medication.
11. A NON-REFUNDABLE enrollment fee of $25 dollars will be charged at the time the child is enrolled for care. In addition a deposit equivalent to one week's tuition will be required to be paid at the time the spot is reserved. This will be applied to the first week's tuition and forfeited if the child does not come for care as agreed. the spot will not be held for more that 24 hours without this deposit.
By signing this contract, parents' / legal guardians agree to abide by the written policies of the provider. signature acknowledges that you have read & signed all necessary forms listed under ADMISSION REQUIREMENTS and agree to abide by them. The provider may amend the policies by giving the parents / legal guardians a copy of the new or changed policies or rates at least two weeks before they go into effect. I acknowledge that I/We understand and will abide by the policies and the terms of this contract.
Provider's Signature _________________________________ Date _____________________________
Mother / Legal Guardian's Signature ___________________________ Date ________________________
Father / Legal Guardian's Signature ___________________________ Date _________________________
CONTRACT
Diana's Lil' Darlings Family Home Childcare
