Fillable Printable Sample Child Care Agreement Form

Sample Child Care Agreement Form

Sample Child Care Agreement

Welcome to my family child care home. The purpose of this agreement is to define the

mutual terms for child care arrangements. Please let me know of any changes of

address or telephone or emergency numbers. Parents are welcome to visit at any time

during child care hours.

Child’s name_____________________________ Date of birth___________________

Parent’s name(s) _______________________________________________________

_________________________________________________________________________________________________________

Hours and Days of Operation

Child care services will begin on __________________________________, 20___

The hours for care will begin at ________a.m./p.m. and end at ______a.m./p.m. 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: ________________________

______________________________________________________________________

My vacation period will be _________________. You will be responsible for making

other child care arrangements. Payment is still expected.

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_______unless

special arrangements have been made.

$____________ per meal. Families are required to bring the appropriate foods

for infants younger than ________ months old.

Child care fees are payable in advance and are due no later than _________________.

Fees may be paid: weekly _____ bi-weekly _____ monthly ______.

An advance deposit of $ ___________ must be paid at the time of enrollment. This

amount will be returned when services are terminated.

Fees may be (or may not be) adjusted when services are not available because of

illness or vacation.

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 me know more about your child.

Language spoken at home:______________________________________________

____________________________________________________________________

How does he or she 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 I receive a signed permission form

stating otherwise from a licensed physician).

Blanket or special toy:___________________________________________________

____________________________________________________________________

General disposition/fears/comforting:_______________________________________

____________________________________________________________________

Favorite songs/games/fingerplays: _______________________________________

____________________________________________________________________

How do you encourage positive behavior: ____________________________________

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:

______________________________________________________________________

Food

Meals will be: _____ Prepared by the provider _____ Brought by family

Meals served will be: _____ Breakfast ____ Morning snack ____ Lunch

____ Afternoon snack ____ Supper ____ Evening snack

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 me if your child will be absent because of illness. If your child is home for

more than _____ days she/he must bring a signed physician’s statement when returning

to the program.

If the child is absent, payment is ________still expected ________ not expected.

Please inform me of any contagious disease immediately. All families of children in my

care will be notified.

If your child becomes ill during care, you will be asked to pick up your child within _____

hours. If you cannot be reached, I 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 ________________________________________________________________

Field Trips

Often we take trips away from my home to help your child learn more about the

community. Your permission is needed to allow your child to ride in my car. You will be

notified in advance when trips are being planned indicating the date, location and

amount of time away from home.

A proper infant seat or child booster seat is required for car travel for any child under the

age of 8. ___You or ___I will provide the seat.

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 __________________________________________________