This is a sample Parent-Provider Agreement. Complete the agreement using your own rules. On a separate sheet of paper, list other rules you want to include.
| PARENT-PROVIDER AGREEMENT |
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Parent-Provider Agreement for (name)________________________________________________ Family Day Care Program. HOURS/DAYS: (Child's name) _____________________________ will join the Family Day Care Program, starting on ______________. The child will arrive mornings by __________ and will be picked up in the evenings by __________p.m. The parent agrees to call me by _________ if he/she will be late and pay an additional charge of $_______ for each________ after. The program will be open as usual for all state holidays except_______________________________________. The following additional times are available _________________________________. FEES: Day care is provided between the hours of ________ and ________ on ________ through ________ at a cost of $_______ per ________. In addition, $________ per ________ will be charged as a late fee. MEALS AND PROGRAM: Each day, _____ snacks will be given at ____:____ and ____:____. Lunch will be served at ____:____. Parents can see a menu for the next week on __________. Special diet includes:________________________________________________________________. Program will include outdoor play, weather permitting, each day and will also include_____________ ______________________. Indoor program may include___________________________. Watching TV is permitted _____. CLOTHING: Parents will provide _____________________________ in summer, ___________________________ in winter and diapers will be provided by _______________. NAPS: Infants will sleep as they need. All other children will rest from ________ to ________ each day. ________________________ will be provided by for napping. FOR EMERGENCIES: Children will be allowed to leave only with parents or other adults listed below: Adult(s) to be contacted when parent cannot be reached: Name _________________________ Phone _________________ Name _________________________ Phone _________________ If child becomes ill during the day, ________________ can be reached at _______________________. The day care provider may call the child's doctor if emergency medical or surgical care is needed for the child. (A conscientious effort will be made to locate the parent first.) Doctor's Name _____________________ Phone ______________ TRAVEL/TRIPS: I, (parent's name)______________________________, hereby give (provider's name)_____________________________ permission to take my child, _____________________, using _______________ on field trips as part of the program. Car seat will be provided by ____________ for this use. SIGNATURES: This agreement will be in effect from ______________ to ______________. It will be reviewed on _____________ and changed as needed. Parent's Signature _______________________ Home Phone ________________ Work Phone _______________ Address (street, city/town) _______________________________________________ Provider's Signature _____________________ Home Phone ________________. |
| Reprinted with permisison from the National Network for Child Care - NNCC. Koehler, C.R. (1991). Parent-provider agreements. (Family Day Care Facts series). Amherst, MA: University of Massachusetts |