INFORMATION AND AGREEMENT 

THE COMPLETED FORM SHALL BE KEPT IN THE CHILDS RECORD AT THE FAMILY DAY HOME. 

 

Child ___________________________________________

 

Nickname__________________________ Sex_________ Birthdate______________________ 

Street Address__________________________________________

 City________________________   State____________  Zip____________________ 

 

 

Home Phone 

Allergies, Chronic Physical Problems/Diseases/Pertinent Development Information/Special Accommodations Needed __________________________________________________________________________________________

___________________________________________________________________________________________

 

 

If Child Attends School/Program, Give Name of School/Program 

 

 

Grade 

Names & Locations of Previous Child Day Care Programs & Schools Attended 

 

 

                                                                                 PARENTS/GUARDIAN 

Father 

 

Place Employed 

Business Phone 

Business Address 

 Business Hours

 

Home Address 

 

Home Phone 

Mother 

 

Place Employed Business Phone 

Business Address 

 

Business Hours 

Home Address (enter same if address is the same as the fathers) 

 

Home Phone 

Person(s) or Agency Having Legal Custody of Child 

 

Home Address 

 

Home Phone 

Business Address 

 

Business Hours 

                                                                                EMERGENCY INFORMATION 

Street Address 

Childs Physician 

City    State Zip 

Phone 

Street Address 

Name of Emergency Contact if Parent(s) Cannot Be Reached 

 

 City                                 State                        Zip 

Phone 

Person(s) Authorized to Visit, Call or Pick Up Child 

 

Person(s) NOT Authorized to Visit, Call or Pick Up Child* 

 

* Appropriate custodial paperwork shall be attached if a parent is not allowed to pick up the child. 

 PART II.  AGREEMENT TO BE COMPLETED BY PARENT(S) OR GUARDIAN 

 

 

I hereby agree to place ______________________________ in the care of ________________________________

between the hours of _______________________________ or ___________ A.M. and __________ A.M. &

__________ P.M. and __________ for __________ days a __________ week, ___________ month. 

 

I agree to pay $______________ per ________ Hour, ________ Day, ________ Week, ________ Month for the care of this child.  Payments are to be made ________ Daily, ________ Weekly, ________ Semi-monthly, ________ Monthly. 

 

I agree to arrange for the necessary medical examination and immunizations for my child prior to or within 30 days after enrollment and I will provide updated Immunization reports as required thereafter; or I will submit the necessary documentation for medical or religious exemption from these requirements. 

 

I agree to pick up or arrange to have my child picked up as soon as possible when notified that he or she develops symptoms of a communicable disease; an oral temperature of 101F or an armpit temperature of 100F; or recurrent vomiting or diarrhea. 

 

I understand that in case of an emergency due to illness the provider will contact the parent(s) or guardian; if the parent(s) or guardian is not available or cannot be reached, the provider will notify the designated emergency contact to pick up the child. 

 

I authorize the Family Day Provider to obtain immediate medical care for my child if an emergency occurs and I cannot be located immediately.  I have completed, signed, and dated the childs emergency medical authorization form.  I authorize the Family Day Provider to provide or arrange for emergency transportation to ____________________________________________________________________ 

or the nearest emergency medical facility if an emergency occurs and I cannot be located immediately. 

 

I understand that the Family Day Provider may give nonprescription medication only as directed by the instructions on the original container and with my written consent. I understand that the Family Day Provider may give prescription medication only as directed by the authentic prescription label and with my written consent. 

 

I understand that childcare providers are to report suspected child abuse or neglect as required by law

 

I understand that as the parent, I must provide my own back-up and that the family provider will not be responsible for providing a substitute provider. 

 

I understand that authorization for field trips will be given on an individual basis. 

 

I have reviewed the discipline policy including the acceptable and unacceptable discipline methods with the Family Day Provider. 

 

Other agreements or acknowledgments:  ______________________________________________________________________________ 

______________________________________________________________________________ 

 

Signature of Parent(s) or Legal Guardian: ____________________________________________________________________________ 

      Date: ________________________________________________________________ 

  

Signature of Family Day Provider:  _________________________________________________________________________ 

Date: ______________________ 

 

Date child withdrawn from home: ________________________________________