Agreement

55 PA CODE CHAPTERS 3270.123 &. 181(C); 3280.123 &. 181(c); 3290.123 181(c);

"*" indicates required fields

Name of Child*

Fee Amount

Per-Day-Week

Day payment to be made*

Private Pay

Subsidy

Services to be provided as part of the day care fee (examples; transportation, care, meals, etc.)

Child's Arrival Time

Child's Departure Time

Person(s) Designated by Parent To Whom Child May Be Released*

Late Fee

Per Min-HR

Extra services to be provided at an additional fee if applicable

I, the parent/guardian;

received complete written program information at the time of enrollment (§ 3270.121, 3280.121, 3290.121)

agree to update the emergency contact/parental consent form information whenever changes occur or every 6 months at a minimum. (§ 3270.124, 3280.124, 3290.124)

Signature-Operator

Date

Signature-Parent or Guardian*

Date*

Date of child's admission

Date of withdrawal

Periodic Review

Signature-Parent or Guardian

Date

03892A

CY 321 - 12/99