Enrollment

Agreement

55 Pa Code Chapters 3270.123 &.181(C); 3280.123 &.181(C); 3290.123 &.181(C)

Name Of Child

Fee Amount

Per-Day-Week

Day Payment To be Made

Signature-Parent Guardian Layout

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

Child's Arrival Time

Late Fee

Child's Deaprture Time

Per Min-HR

Person's Designated By Parent To Whom Child May be Released

Extra Services to be provided at an optional 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 minumum. (§ 3270.124, 3280.124, 3290.124)

Signature-Operator

Clear Signature

Date

Signature-Parent OR Guardian

Clear Signature

Date

Date Of Child's Admission

Date Of Withdrawal

Periodic Review

Signature-Parent OR Guardian

Clear Signature

Date

Emergency Contact / Parental Consent Form

55 Pa Code Chapters 3270.124 (A) (B), 3270.181 & 182; 3280.124 (A) (B), 3280.181 & .182; 3290.124 (A) (B), 3290.181 & .182

Child’s Name

Date Of Birth

Address

Parent’s Name/Legal Guardian

HOME TELEPHONE NUMBER

Address

Business Name

Business Telephone Number

Address

Emergency Contact Person(s)

Name

Telephone Number When Child Is In Care

Person(s) To Whom Child May Be Released

Name

Address

Telephone Number When Child Is In Care

TELEPHONE Signature

Name Of Child’s Physician/Medical Care Provider

Telephone Number

Address

Special Disabilities (If Any)

Allergies (Including Medication Reaction)

Medical Or Dietary Information Necessary In An Emergency Situation

Medication, Special Situation

Additional Information On Special Needs Of Child

Health Insurance Coverage For Child Or Medical Assistance Benefits

Policy Number

PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

Obtaining Emergency Medical Care

Admin. Of Minor First-aid Procedures

Walks And Trips

Swimming

Transportation By The Facility

Wading

Periodic Review

Signature Of Parent Or Guardian

Clear Signature

Date

Agreement

Periodic Review

Emergency Contact / Parental Consent Form

Emergency Contact Person(s)

Person(s) To Whom Child May Be Released

Name Of Child’s Physician/Medical Care Provider

PARENT’S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT

Obtaining Emergency Medical Care

Admin. Of Minor First-aid Procedures

Periodic Review

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