I/We, _________________________________ , agree that Megan. A. Laprade will care for my/our child(ren),
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Care will be provided on a Drop-in, as needed and space is available, basis. I/We understand that the fee for Drop-in Care is $5/hour with a maximum charge of $35/day per child. I/We also know that there is a 20% discount for multiple children. I/We agree to pay Megan. A. Laprade when I/we pick my/our child(ren) up from Play All Day Home.
Care will include meals and snacks according to the time of day the child(ren) are in care.
This also certifies that the parents have read, agreed to, and signed all the childcare Policies. These policies are legal and binding. Parents have also provided accurate information on the following form: Child Admission Record.
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Mother�s Signature Date
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Mother�s Street Address Mother�s Contact Phone
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Father�s Signature Date
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Father�s Street Address Father�s Contact Phone
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Provider�s Signature Date
I herby give permission for my child/children ________________________________________
may be given emergency treatment (first aid and CPR) by a qualified staff member at (Play All Day Home) Day Care.
I also give my permission for my child/children to be transported by ambulance, aid car, or staff car to an emergency center for treatment.
In the event that I cannot be contacted, I further consent to the medical, surgical, and hospital care treatment and procedures to be performed for my child by a licensed physician or hospital when deemed immediately necessary or advisable by the physician to safeguard my child�s health.
In case of emergency, and if emergency transportation is needed, I________________________________
agree to pay all costs of transportation.
Child�s physician:_________________________________________________________________________
Physician�s address:.______________________________________________________________________
Preferred hospital:.________________________________________________________________________
Hospital address:__________________________________________________________________________
Clinic or Hospital phone number:_____________________________________________________________
Medical insurance:________________________________________________________________________
Insurance numbers:_______________________________________________________________________
Date of last tetanus (or DPT)________________________________________________________________ Allergies:________________________________________________________________________________
Father�s name:______________________________________________________________________
Mother�s name:______________________________________________________________________
Father�s signature:____________________________________________Date:__________________
Mother�s signature:.___________________________________________Date:__________________