I CAN BE ME DAYCARE

PARENT-PROVIDER AGREEMENT
I,______________________________________________________________________ agree to enroll

_________________________________________________________________age________________.

in the Family Child Care Home of Nancy Michaud. I have received and read the Family Child Care Home Rules nd Regulations and agree to comply with all the rules and responsibilities as stated. I have received a copy of the current daycare fees and corresponding fee payment schedule which includes all times the facility is closed to childcare. This contract is valid beginning ___________. I understand that a two week notice in writing is required to change or terminate this agreement.

I understand that a full day of child care is from 7am-6pm and that Full-Time Care is five full days, Monday through Friday. I understand that Part-Time Care is limited to the hours for which I have contracted and all care provided is subject to space availability based on license capacity.

I understand that the fee due Nancy Michaud depends on the type of care for which I have contracted and is not necessarily based on the actual hours childcare is provided. I understand that payment for the week of service is due at the beginning of the each week. I have agreed that my minimum fee is $______per week based on _____hrs and that childcare provided beyond my contracted hours will be billed at $4.00 per hr. I understand that a $15.00 late fee will be charged to my account for a payment that is 30 days past due. I have been informed that a Security Deposit is due prior to the first day of childcare and that the amount paid for deposit will be held in an account and applied to the last two weeks of the contracted care. I have agreed that my deposit will be ______ and is non-refundable. I have been informed that if I am contracting for Before and After School or After School Only childcare, that I will need to pay a non-refundable deposit by April 1st in order to guarantee a Full-Time Summer childcare space.

Please indicate the type of service and the months, days, and hours that apply to your needs:
Part-time___ No. of hrs. per wk______ Hrs. are M________T________W________Th________F________
Jan Feb March April May June July August Sept Oct Nov Dec
Full-time ___ Monday thru Friday 7am to 6pm.
Jan Feb March April May June July August Sept Oct Nov Dec
Before and After School ______________ / After School Only_____________
Early September to Mid-June
Earlybird/Latebird_______Hours_________ M T W Th F
Summer Only______ Full-time______ Part-time____ M T W Th F Hrs. per wk______
Mid June to end of June July August

SIGNATURE(S) OF PARENT(S) OR LEGAL GUARDIAN
X__________________________________/_____________ SS#________-_____-_________
date
X_________________________________/______________ SS#________-_____-_________
date
I agree to live up to my responsibilities as a Licensed Child Care Provider
SIGNATURE OF CHILD CARE PROVIDER __________________________________/___________
SS#_______-____-________ date

***************

I CAN BE ME DAYCARE

Enrollment Form

I. Basic Information
A. Name of Child: _______________________________ Birthdate: ____________
B. Mother’s Name: ______________ Home Phone: ________ Work Phone: _______
C. Father’s Name: ______________ Home Phone: ________ Work Phone: _______
D. Child lives with: ___ mother ____ father ____ other (name)___________
E. Names of other Siblings: _____________________________________________
II. Pick-up Permission
A. The following people HAVE permission to pick-up my child(ren) from I Can Be Me Daycare. It is the client’s responsibility to notify me in writing of any changes.
1. Name: __________________ . Phone #: ___________ Relation: _________
2. Name: __________________ . Phone #: ___________ Relation: _________
3. Name: __________________ . Phone #: ___________ Relation: _________
4. Name: __________________ . Phone #: ___________ Relation: _________
B. The following people MAY NOT pick-up my child(ren) from I Can Be Me Daycare:
1. Name: _____________________________
2. Name: _____________________________

III. Health Background
A. List any health problems your child has incurred in the past year:
______________________________________________________________________
______________________________________________________________________
B. List any special needs your child requires: __________________________
C. List any foods your child may NOT be given: __________________________
D. List any current medications: ________________________________________
IV. Developmental Background
A. Name of previous childcare facilities: ______________________________
B. Does your child have any special fears: _____________________________
C. Child’s favorite foods/activities: __________________________________
D. Nap patterns/procedures: ____________________________________________
E. Toilet times/habits/problems: _______________________________________
F. Child’s normal eating times/habits/problems: _________________________________________________________________________________
G. What is your child’s most difficult behavior to deal with: ___________________________________________________________________________________
H. What frustrates/upsets your child: ___________________________________________________
I. Describe most common family rules that you expect your child to followin your home: _________________________________________________________________________________
J. What method of discipline works best with your child and when do youuse it: _________________________________________________________________________________
V. Pre-Kindergarten Skills
Please check all the skills you feel your child has mastered and indicate which ones he/she is currently working on.
A. _____ Knows address K. ____ Recognizes lower case letters
B. _____ Knows phone number L. ____ Recognizes letter sound
C. _____ Knows birthdate M. _____ Likes to listen to stories
D. _____ Can say full name N. _____ Can tie shoes
E. _____ Can print full name O. _____ Can button own clothes
F. _____ Counts to... P. _____ Can tell time
G. _____ Knows right from left Q. ___ Has experienced crayons
H. _____ Knows names of colors R. ___ Has experienced scissors
I. _____ Can recognize numbers 1-12 S. ___ Enjoys music
J. _____ Recognizes capital letters T. ___ Can read