Child Care Agreement
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1DIVISION OF CHILD CARE AND EARLY LEARNING
CHILD CARE AGREEMENT
FIRST NAME
MIDDLE NAME
LAST NAME
Child's name:
FIRST NAME
MIDDLE NAME
LAST NAME
Parent or guardian's name:
Days and times my child will receive care:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Check day(s) of care
Arrival time
Departure time
Date payment due:
FEE: $_____________________ per:
Hour
Day
Source of payment:
Week
Parent
Month
Other (specify):
Overtime rate: $
per
Late fee: $
per
I agree to promptly notify the child care provider of any changes of the above information. I understand that I am
fully responsible for the terms of this agreement as stipulated.
I have read, understand, and agree to comply with the policy and procedures, information for parents given
to me by
.
NAME OF PROVIDER
PARENT OR GUARDIAN'S SIGNATURE
DATE
PARENT OR GUARDIAN'S SIGNATURE
DATE
I agree to provide child care services according to the above plan. I agree to promptly notify the parent(s) or
guardian(s) of any changes to the above information.
PROVIDER'S SIGNATURE
DATE
STREET ADDRESS
CITY
STATE
ZIP CODE
COMMENTS
DSHS 10-096(X) (REV. 02/1997) (AC 09/1997)
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