Parent Withdrawal Form printable pdf download

Parent Withdrawal Form

Date: _________

I _________________________

will be withdrawing my

(print parent name)

child/children _________________________________

(print child/children’s name)

from Helping Hands Childcare.

Our last day of child care will be

____________________

(date).

Please accept this as my TWO WEEK’S NOTICE for withdrawal of my

child/children as required by my Parent & Provider Contract Agreement.

Reason(s) for leaving:

 Moving

 Child aging out

 Challenging Behavior

 Rates are too high

 Policy Issues

 Change in child care needs

 Other

: _______________________________________________________

(please explain)

To help me serve my clients better and continue growing, please answer the following:

 Yes  No, why not: _______________________________

Would you refer me?

 Yes  No, why not: _______________________________

Would you use me again?

Comments or suggestions: ____________________________________________________

___________________________________________________________________________

Parent Signature: ____________________ Date: _________

Provider Signature: __________________ Date: _________

_____ I have received ALL personal belongings.

(Initials)

Helping Hands Childcare * 1225 Nilgai Place * Ventura CA 93003 * 805-323-6860

Parent Withdrawal Form