PROVIDER-PARENT/GUARDIAN
CHILD CARE CONTRACT
Welcome! I’m glad you have decided to enroll your child in my family daycare. (You are welcome to contact
4-C certification, who I am certified through (271-9181) to verify my status of certification or should you have any concerns) As a certified provider, I can care for up to 3 children in addition to my own, under the age of 7 years, at any one time. Along with enrollment materials, parents will receive a copy of a parent checklist which summarizes certification regulations. The following contract is to be completed and signed by the parent/guardian before care begins. Please read over all policies and fees before signing the contract. We must discuss fees and what services are covered before care begins. You will receive a copy of the signed contract. If you have any questions regarding fees, policies or practices, please feel free to discuss them with me.
This Contract is Between:
-And-
Mother/Legal Guardian
Name:______________________ Address:____________________________Phone:_________________
Employer:___________________ Address: ____________________________Phone:________________
Father/Legal Guardian
Name:______________________ Address:_____________________________Phone:________________
Employer:___________________ Address: ____________________________ Phone:________________
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For the Care of: |
1. |
Child’s Name:____________________________ |
3. |
Child’s Name:___________________________ |
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Date of Birth:____________________________ |
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Date of Birth:___________________________ |
2. |
Child’s Name:____________________________ |
4. |
Child’s Name:__________________________ |
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Date of Birth:____________________________ |
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Date of Birth:___________________________ |
I may amend the contract/policies by giving the parent/guardians a copy of the new or changed policies at least _______weeks before any changes go into effect.
PAYMENT AND FEES:
Hours of Care Needed: (Be sure to specify if AM or PM)
TIMES |
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
Saturday |
Sunday |
Drop Off |
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Pick Up |
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Payment for Care Provided: (please circle one)
1st Child: $_______________/per week $ ______________/per day $ _____________/per hour
2nd Child: $_______________/per week $ ______________/per day $ _____________/per hour
3rd Child: $_______________/per week $ ______________/per day $ _____________/per hour
Payments are due:________________________
Additional Fees/Late Fees: (If applicable, please check one, indicate $ amount)
Parent’s will be charged additional fees for early drop off or late pick up. Fees are as follows: $_________/per minute
$_________/per every ____minute increment $_________/per ½ hour.
Parent’s will not be charged a late fee for early drop off or late pick up.
Holidays: (please check all holiday’s that childcare will be closed)
Not Applicable |
Martin Luther King, Jr., Birthday |
Memorial Day |
Independence Day (4th of July) |
Labor Day |
Thanksgiving Day |
Christmas Day |
New Years Day |
Other:________________________________ |
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(check all statements that apply)
Holidays provider does not provide care will be paid at a rate of:_______________________.
Holidays provider does not provide care will not be paid by parent.
Holidays parent does not bring child to care and childcare is open will be paid at a rate of:______________________.
Holidays parent does not bring child to care and childcare is open will not be paid.
Payments made by other sources (W-2):
The Dane County subsidy program (W-2) will pay certified providers for days of attendance only. They do not pay providers for sick days, vacation days or days the child is not authorized for. Therefore, it is my policy:
Parent’s will be responsible for payment on days the county/city does not make payment and the child does not attend childcare. Payment will be paid at a rate of: ___________________________________.
Parent’s will not be responsible for payment on days the county/city does not make payment and the child is not in care.
Vacations: (list any vacations that are agreed upon per year and if payment is expected)
Vacations for provider will be paid by parent, at a rate of:___________________________________.
Vacations provider will take:____________________________________________________.
Vacations for provider will not be paid.
Vacations for parents will be paid by the parent at a rate of:__________________________________.
Vacations parent will take:______________________________________________________.
Vacations for parents will not be paid.
Absences:
Absence or illness of a child will be paid by the parent at a rate of:_____________________________.
Absence or illness of a child will not be paid.
If I (the provider) close my daycare due to my illness or the illness of a family member, the rate of pay will remain unchanged.
If I (the provider) close my daycare due to my illness or the illness of a family member, payment is not required.
Additional Requirements: (please list any additional items the parent(s) are expected to provide-items may include, diapers, lotions, sun screen, blankets, pillows, change of clothing etc.)
Parent is not responsible for additional requirements.
Parent is responsible for the following additional requirements:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Termination: (Please refer to policies section under TERMINATION for explanation of “termination period”)
Termination of care for a child(ren) by the provider will be paid by parent during the termination period.
Termination of care for a child(ren) by the provider will not be paid for the termination period.
Termination of care for a child(ren) by the parent will be paid for the termination period.
Termination of care for a child(ren) by the parent will not be paid for the termination period.
By signing this contract, parents/guardians and provider agree to abide by the written policies as
stated above.
________________________ |
_______________________ |
__________ |
Provider’s Name (Print) |
Provider’s Signature |
Date |
________________________ |
________________________ |
_________ |
Parent’s Name (Print) |
Parent’s signature |
Date |
________________________ |
_______________________ |
_________ |
Parent’s Name (Print) |
Parent’s signature |
Date |
Attention Parent(s): Certification requires all parents receive a signed copy of the
contract. Please be sure to obtain a copy of this contract.
may be submitted within 30 days after enrollment
POLICIES AND PROCEDURES AGREEMENT:
Admission:
My family childcare will provide care for children between the ages of ______weeks/months/years (circle
one) through ______years. My operating hours are between _____am/pm and ____am/pm. Please be aware
that although I specify my hours of operation, we will contract for specific hours for your child and you may be charged additional fees if you pick up or drop off your child beyond our contracted hours (see contract). I will never refuse to enroll a child on the basis of race, color, sex, sexual orientation, creed or handicap.
Enrollment Procedures:
Parents must meet with the me (the provider) in order to discuss their child’s specific needs and to review the program’s policies. The following forms are required to be on file for each child per certification standards:
Parent information and checklist (to be completed by provider and parent together) Enrollment and emergency medical consent form
Authorization to administer medication form Authorization to transport (vehicle or walking field trips) Immunization Record
Health Report (needs to be completed by physician) may be submitted within 90 days after enrollment Information for children under 2
Completed and signed contract. Policies and Procedures reviewed.
All families will be enrolled on a trial period. The trial period of _________________ is to determine the
right placement for your child. During this trial period either party (parent or provider) has the right to terminate care without notice. Your trial period will end on ____________________. Please make a note of
this day. After the trial period, termination notice must be given. The parent will be responsible for payment for days the child attended during the trial period.
Termination:
This contract may be terminated by either the parent/guardian or provider by giving a ______week written
notice in advance of the ending date. Payment by parent/guardian may be due for the notice period, whether or not the child is brought to the provider for care (please refer to the contract). Reasons for a provider termination may include but are not limited to: failure of parents/guardians to pay, failure of parent/guardian to complete required forms, lack of parent cooperation, inability of provider to meet the child’s needs, the inability of the child to adjust to childcare or the failure of parent to abide by contract/policies. In some cases, immediate termination may be necessary. Some reasons for immediate termination may include, but are not limited to; failure for a parent to pay required fees, health or safety reasons of the children in care. Communication between parents and the provider is very important. Termination due to any of these reasons would be a last resort of parents/guardian and provider being unable to resolve the issue together.
Liability:
This family childcare is covered by liability insurance both for my premises and for my operations. Name of insurance company:_______________________________________.
This family childcare is not covered by liability insurance.
This family childcare has vehicle insurance to cover transporation of daycare children.
This family childcare does not have vehicle insurance to cover transportation of daycare children.
Illness Policy:
It is not always easy to decide if a child should remain at home due to an illness. Children who come to childcare are expected, with few exceptions, to participate fully in child care activities. Children who are exhibiting the following symptoms will be sent home or should remain home:
Fever of 100 degrees or higher: this signals an illness may make a child uncomfortable and unable to to function well in childcare.
Vomiting, diarrhea or severe nausea: these are symptoms that require a child to remain at home until a normal diet is tolerated the night before and the next morning.
Rashes: rashes or patches of broken, itchy skin should be examined by a doctor if it appears to be spreading or not improving.
A child who is too ill to remain in care will be isolated from the other children. The parent will be notified of their child’s illness and will be required to pick up their child within______minutes.
Children with communicable diseases shall not attend childcare. Examples of communicable diseases include but are not limited to:
Chicken Pox |
Influenza |
Pink Eye |
Mumps |
Strept Throat |
Impetigo |
Lice |
Measles |
Whooping Cough |
Scarlet Fever |
It is important that you notify the provider if any medication has been administered to your child within the last 24 hours. Should there be a medical emergency it is crucial to report whether or not the child is on medication.
All prescriptive and non-prescriptive medications (including diaper rash creams and sunscreens) that need to be administered at childcare by the provider requires that the parent complete an Authorization to Administer Medication Form.
Health Procedures:
Each child 5 years of age or younger and is not enrolled in school, is required to have a physical examination report on file within 90 days of the first day of attendance. Children age 2 years and older must submit an updated Health Report Form every 2 years. Children under 2 must submit an updated Health Report Form every 6 months. An immunization record for all children must be completed by the parent within 30 days of the first day of attendance.
Sudden Infant Death Syndrome (SIDS):
According to certification standards, all providers, employees, substitutes and volunteers of a provider who provide care and supervision for children under one year of age shall receive training in the most current medically accepted methods of preventing sudden infant death syndrome (SIDS) before the date on which the provider is certified or the employment or volunteer work commences.
In addition to myself, my substitutes/volunteers have completed an approved SIDS training. I completed the training on:________________. This can be verified with the 4-C office at 271-9181.
I have not completed an approved SIDS training and can not care for children under 1 year of age until an approved SIDS training has been completed.
In addition, it is the policy of this childcare and a certification standard that all infants under 1 year of age must be placed on their backs to sleep to reduce the risk of SIDS, unless otherwise instructed/directed in writing by the child’s physician. A safe crib or playpen shall be available for each child under 1 year of age to use for napping.
Discipline:
In accordance with Wisconsin rules for Family Daycare Certification punishment that is humiliating or frightening to a child such as hitting, spanking, verbal or sexual abuse, withholding or forcing food, binding or tying to restrict movement, enclosing a child in a confined space such as closet, basement, locked room, box (or similar cubicle) any punishment for lapses in toliet training and any forms of physicial punishment are prohibited. Time-outs can not exceed 5 minutes. These forms of punishment will never be used, even at a parent’s request.
My childcare will use the following methods to guide the child rather than discipline:_____________
______________________________________________________________________________
Substitute Care Arrangement:
A substitute provider is considered someone who provides care on a regular weekly basis and must meet the same qualifications as a certified provider (training, continuing education, SIDS and background checks). All substitute providers must be approved through 4-C.
Not Applicable. Parents will be required to provide their own childcare if I (the provider) am unable to do so due to illness, closings or scheduled vacations.
Substitute Care Provider(s) may be the following individual(s):
Substitute #1 Full Name:___________________________Phone:____________________
Substitute #2 Full Name:___________________________Phone:____________________
The provider has also identified an emergency backup person that may be called for assistance in the event of an emergency : ___________________________________________________________.
Additional Policies Include:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
By signing this agreement, you are agreeing you have read, understand and agree to adhere to these
Policies and Procedures
________________________ |
_______________________ |
__________ |
Provider’s Name (Print) |
Provider’s Signature |
Date |
________________________ |
________________________ |
_________ |
Parent’s Name (Print) |
Parent’s signature |
Date |
________________________ |
_______________________ |
_________ |
Parent’s Name (Print) |
Parent’s signature |
Date |
Attention Parent(s): Certification requires all parents receive a signed copy of the
contract. Please be sure to obtain a copy of this contract.
SAMPLE TERMINATION NOTICE
PARENT TERMINATION
Notice given by: ______________________________on __________________
Parent/Guardian’s NameDate
to terminate care for:___________________________effective:__________________.
Child/Children’s nameDate
_______________________________________ |
_____________ |
Parent’s Signature |
Date |
PROVIDER TERMINATION
Notice given by: ______________________________on ___________________
Provider’s NameDate
to terminate care for: _____________________________effective: ________________. Payment
Child/Children’s Name(s)Date
of __________________ will be due. If parent wishes not to have their child attend childcare after
termination notice has been given:
Payment will be required from last date of attendance to termination date.
Payment will not be required.
__________________________________ |
____________ |
Provider’s Signature |
Date |
