Parent Agreement Form

Name of Child*
First Last
Parent's Name*
First Last
Parent's Email*
Fee Amount
Per-Day-Week
Day Payment To Be Made
Services to be provided as part of the day care fee
Examples: transportation, care, meals, etc.
Child's Arrival Time

: Hour

Minute
Child's Departure Time

: Hour

Minute
Late Fee
Per Min-HR
Person(s) designated by Parent to whom child may be released
Extra services to be provided at an additional fee if applicable
Date of Child's Admission
MM
DD
YYYY
Date of Withdrawal
MM
DD
YYYY
Consent*
- I, the parent/guardian, received complete written program information at the time of enrollment. (§ 3270. 121, 3280. 12 1, 3290. 121)
- I, the parent/guardian, agree to update the emergency contact/parental consent form information whenever changes occur or every 6 months at a minumum. (9 3270. 124, 3280. 124, 3290. 124)
Today's Date*
Date Format: MM slash DD slash YYYY