Family Day Care Admission And Arrangements
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1
2Lauri’s In-Home Childcare
Family Day Care Admission and Arrangements
6118 Kahl Ave NE
Albertville, MN 55301
Complete one form for each child. This form must be kept on file at the family day
763-497-9776
care home. The information requested on this form is necessary for proper care of
your child. You are not legally required to supply this information; however, failure to
do so will make you ineligible to receive family day care services from me. (MN Rule,
Parts 9502-0300 to 9502-0445 Formerly Rule 2). The information requested will be
maintained in a private manner and will not be released to anyone other than the
licensing consultant without your prior written approval.
Child’s Information
Name
______________________________ D.O.B._____ Age____ Date of Enrollment_________
(First,Middle and Last)
Address _________________________________________________ Phone Number__________________
Special Conditions
______________________________________________________
(Special Diet, Special Needs)
Please list any known allergies_______________________________________________________________
Child’s typical Schedule____________________________________________________________________
______________________________________________________________________________________
My hours of care will be from 6:30 AM to 5:00 PM, Monday through Friday.
Please circle below the day’s your child will be attending.
Monday
Tuesday
Wednesday
Thursday
Friday
The drop-off time for your child is ___:___ [AM / PM].
The pick-up time for your child is ___:___ [AM /
PM].
(
Any parent picking up their child/ren after the designated time will be charged $15.00. There will be an additional charge of $5.00 for EVERY 15 minutes past the
designated pickup time. This amount will be due at the time you pick up your child/ren).
The regular rate will be $ _____ per week. This fee could change with a minimum of two week’s notice. If you are receiving subsidy
payments from a government agency, you are responsible for paying the full amount of the fees under this contract if the
government agency does not pay me for any reason. The co-pay will be $ _____ per week. These rates will be charged regardless
of the child’s attendance. Payment is due on Friday at the time of pick up or on the last day of care for the week.
Parent’s Information
Mothers Information
Fathers Information
Name:_____________________________________
Name:_____________________________________
Home Address:_____________________________
Home Address:______________________________
___________________________________________
___________________________________________
Home Phone: _______________________________
Home Phone: _______________________________
Employer:__________________________________
Employer:__________________________________
Email:_____________________________________
Email:_____________________________________
Work Phone:________________________________
Work Phone:________________________________
Cell Phone:_________________________________
Cell Phone:_________________________________
Physician Information
The following Physician is authorized to give emergency care to my child. If unavailable, another licensed Physician may
treat my child. _____Yes ____NO
Physician’s Name:________________________________ Name of Clinic____________________________________
Phone Number:______________________ Address:____________________________________________________
Name of parent’s Insurance Company___________________________ Contract No.___________________________
Group No._______________________________
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