Contract

Yr      ________        Date     ____________

Infant _________     Toddler  ____________

Start Date      _________________________     End Date  __________________________


Child(s) Name _________________________    D.O.B     ___________________________

Mom Name    __________________________  Dad Name ___________________________

Work/Celll #   __________________________  Work/Cell #__________________________

Address        ___________________________  Home Phone #________________________


List Hours,  Days and Time that Care will be provided

Full Time ___ Rate ______ Monday____   Tuesday____ Wednesday_____ Thursday _____

Part Time ___ Rate ______Monday____   Tuesday____ Wednesday_____ Thursday _____

Daily Rate ___ Rate _____ Monday____   Tuesday____ Wednesday_____ Thursday _____

Drop Ins  ___ Rate ______Monday____   Tuesday____ Wednesday_____ Thursday _____


List Emergency Name, Numbers and Relation to child

Name___________________  Relation  ____________________  Phone # _______________

Name __________________  Relation  ____________________  Phone # _______________

Name __________________  Relation  ____________________  Phone # _______________


List persons In case of Emergency To authorize To pick up  in any case of emergency

Name __________________  Relation  ____________________  Phone # _______________

Name __________________  Relation  ____________________  Phone # _______________

Name __________________  Relation  ____________________  Phone # _______________


Allergies____________________________________________________________________

Health Conditions ____________________________________________________________

Families Vacations____________________________________________________________

Parent(s) Signature _________________________   Date____________________________

Caregiver Signature _________________________   Date____________________________
                    Last Updated April 28 2003