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
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.
$____________ 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:___________________________________________________
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:
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.
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 whenthe child is no longer sick.
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
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.
Often we take trips away from my home to help your child learn more about the
community. Your permission is needed to allowyour 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
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 __________________________________________________