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DAYCARE AGREEMENT

Mother________________________________ Home Phone #_________________

Address________________________________ Cell or Other #_________________

_______________________________________ Email Address_________________

Employer ______________________________ Work Phone #_________________

Employer's Address ______________________ Work Hours __________________

_______________________________________

Father_________________________________ Home Phone #_________________

Address_________________________________ Cell or Other #_________________

_______________________________________ Email Address_________________

Employer________________________________ Work Phone #_________________

Employer's Address________________________ Work Hours___________________

________________________________________

Child's Name____________________________ Date of Birth __________________

Services to be provided:

Days & hours of care ____________________________________________________

Rate and Payment policies:

Rate $_________________________Due:__________________________________

Daily rate is as follows: 28.00 per day.

Holidays/Vacations/Absences:

Parents/guardians understand the provider is closed on the following days: Thanksgiving

Day, Christmas Day and the week between Christmas and New Years Day. If the child is

unable to attend due to illness or other emergency, this will be paid. If provider is unable

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to provide care due to illness or other emergency, this will be unpaid.

Termination Procedures:

Either parent/guardian or the provider may terminate this contract with a two weekadvance notice.

Emergency contacts authorized & able to pick up child quickly in emergency cases

if parents can't be reached:

Full Name________________________________ Home Phone #_________________Address__________________________________ Cell or Other #________________

________________________________________ Relationship to child____________

Second Choice____________________________ Home Phone #_________________

Address_________________________________ Cell or Other #_________________

_______________________________________ Relationship to child_____________

Other adults authorized to pick up the child from Amy Folkers:

Name:__________________________________ Phone #_______________________

Name:__________________________________ Phone #_______________________

Name:__________________________________ Phone #_______________________

Please indicate below if there are any people who ARE NOT allowed to pick up your

child.

Medical Authorization:

Amy Folkers has permission to provide all personal care to my child____________

including medical attention authorized by a medical doctor. It is understood and

authorized that my child may be transported to the nearest medical facility or

hospital. All expenses including ambulance transportation will be provided by:

Name of responsible party's insurance company________________________________

Contract #______________________________ Group #________________________

Medical/Dental Information:

Physician's Name________________________ Phone #_________________________

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Clinic Name & Address___________________________________________________

Medicine Allergies_____________________ Medications your child is on___________

Another licensed physician may treat my child_________ Child's blood type_________

Dentist's Name________________________ Phone #___________________________

Clinic Name & Address___________________________________________________

Name of responsible party's dental insurance company___________________________

Contract #___________________________ Group #___________________________

Another licensed dentist may treat my child_________

Permission is given to transport my child for outings/field trips/school, etc._______

Any known allergies

__________________________________________________________________________________________________________________________________________

Special Needes (diet or other)

_______________________________________________________________________

___________________________________________________________________

Signatures:

I/We have read, fully understand and agree to this contract. I/We understand that

Amy Folkers, the provider may amend the policies at any time by giving the parents

a copy of the new or updated policy at least two weeks prior to becoming effective.

This contract is entered into by the parents and provider and will remain in effect

until termination of care OR the signing of a new contract. By signing below, all

parties agree to the contract terms and understand this is a legal binding document.

_____________________________________________________________________

(Parent or Guardian) (Date)

_____________________________________________________________________

(Parent or Guardian) (Date)

_____________________________________________________________________

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(Provider) (Date)