CERTIFIED FAMILY CHILD CARE CONTRACT Provider Parent(s

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CERTIFIED FAMILY CHILD CARE CONTRACT

Welcome! I am glad you have decided to enroll your child in my Certified Family Child Care. Should you have any

concerns or wish to check the status of my Certification, please feel free to contact my regulatory agency, 4-C at

(608) 271-9181. As a certified provider, I can care for up to three unrelated children in addition to my own, under

the age of 7 years, with a maximum group size of six, at any one time. Along with enrollment materials, you will

receive a copy of a Parent Information Checklist, which summarizes additional certification regulations.

The following contract must be fully completed and signed before care can begin. After reading this contract and

the policies thoroughly, please discuss concerns with me before you sign. We will agree upon fees, policies or

practices before care will begin. You will receive a copy of the signed contract.

(Name of Certified Family Daycare)

_____________________________

(Address of Certified Family Daycare)

______________________________________________________________

Provider

Provider’s Name: ___________________________________ Phone Number: ___________________

I provide care for children between the ages of ______weeks/months/years

(circle one) through

______ weeks/months/years

(circle one).

My operating hours are as follows: _______________________________________________________

Please be aware that although I specify my hours of operation, we will contract for specific hours for your child and

you may be charged additional fees if you pick up or drop off your child beyond our contracted hours.

Parent(s)/Legal Guardian(s):

Name: ___________________________________________ Phone Number: ___________________

Children in Care

Name: ___________________________________________ Date or Birth: ______/______/________

Name: ___________________________________________ Date of Birth: ______/______/________

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Enrollment Procedures:

 There is no deposit fee.

 There is a $_________ deposit fee.

 This deposit is non-refundable.

 This deposit is only refundable should termination occur during the trial period.

You must meet with the me in order to discuss your child’s specific needs and to review the program’s policies.

All families will be taken on a trial period of __________day(s)/ week(s)

(provider circles one) to determine the right

placement for your child. During this trial period either parent or provider has the right to terminate care without

notice. You will be responsible for payment for days your child attended during the trial period.

The following forms must be completed and returned to me by ____/____/____ before care will begin:

 Day Care Child Enrollment and Health History

 Authorization to Administer Medication

(as applicable- includes sunscreen, bug repellant and diaper cream)

 Authorization to Transport (vehicle or walking field trips)

 Immunization Record (may be submitted within 30 days after enrollment)

 Health Report (needs to be completed by physician- may be submitted within 90 days after enrollment)

 Information for children under 2 (as applicable)

 Certified Family Child Care Contract.

Rates and Hours of Care Needed PER CHILD:

1

st

Child: __________________________________________

Provider chooses and completes the following:

$_______________/per week $ ______________/per day $ _____________/per hour

Parent/Guardian completes the following:

Monday

TIMES

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Drop Off

Pick Up

2

nd

Child: __________________________________________

Provider chooses and completes the following:

$_______________/per week $ ______________/per day $ _____________/per hour

Parent/Guardian completes the following:

Monday

TIMES

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Drop Off

Pick Up

3

rd

Child: __________________________________________

Provider chooses and completes the following:

$_______________/per week $ ______________/per day $ _____________/per hour

Parent/Guardian completes the following:

Monday

TIMES

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Drop Off

Pick Up

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Payments Due

: (provider chooses one)



Monthly : ________________________

 Biweekly: ________________________

 Weekly: __________________________

 Daily: ____________________________

Additional Fees/Late Fees

: (provider chooses one)

 You will be charged additional fees for early drop off or late pick up. Fees are as follows:

 $_________/per minute

 $_________/per every ____minute increment

 $_________/per ½ hour.

 You will not be charged a late fee for early drop off or late pick up.

Child and Provider Absences

ILLNESS

If I or one of my family members is ill:

 My day care will be closed.

 You will be responsible for regular payment

 You will not be responsible for payment

 My Approved Substitute Care Provider(s) may provide care in my absence and you will be responsible for

regular payment.

If your child is ill:

 You will be responsible for regular payment

 You will not be responsible for payment

VACATION

If I am taking a vacation I will give you _________ notice.

 My day care will be closed.

 You will be responsible for regular payment

 You will not be responsible for payment

 My Approved Substitute Care Provider(s) may provide care in my absence and you will be charged regular

tuition fees.

If you take a vacation you need to give me ________ notice.

 You will be responsible for regular payment

 You will not be responsible for payment

Please keep in mind: The Dane County subsidy program (W-2) will pay certified providers for days of

attendance only

. They do not pay providers for sick days, vacation days or days the child is not authorized for.

Therefore, it is my policy:

 You will be responsible for payment on days the county/city does not make payment and your child does

not attend childcare. Payment will be charged at regular rate.

 You will

not be responsible for payment for the days/hours the county/city does not make payment and

your child is not in care.

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Holidays:

(provider checks all holiday’s that daycare will be closed)

 Not Applicable Martin Luther King, Jr., Birthday

 Memorial Day Independence Day (4

th

of July)

 Labor Day Thanksgiving Day

 Christmas Day New Years Day

 Other:________________________________

Holiday Fees:

(provider checks all applicable)

 You will be charged regular tutition rates for any holiday my family daycare is open.

 You will be charged should my daycare be closed on a holiday.

 You will not be charged should my daycare be closed on a holiday.

Liability:

(provider chooses one)

 This family childcare is covered by liability insurance, both for my premises and for my operations.

Name of insurance company:_______________________________________.

 This family childcare is not covered by liability insurance.

Illness Policy:

You must notify me of any medication that has been administered to your child within the last 24 hours. In case of

a medical emergency I must report whether or not the child is on medication.

You must complete an Authorization to Administer Medication Form for all prescriptive and non-prescriptive

medications that need to be administered at childcare.

You will be contacted immediately should your child become sick or injured. Sick children will be isolated from

other children and made as comfortable as possible.

Children will be required to be picked up within______minutes by you or another authorized person stated on the

enrollment form.

Children who are exhibiting the following symptoms will be sent home or should remain at home:

• Fever of 100 degrees Fahrenheit or higher (99 degrees Fahrenheit or higher for children under the

age of 4 months)

• Vomiting, diarrhea or severe nausea (within a 24 hour period)

• Rashes or patches of broken skin

A child who has or had a communicable disease under HFS 145 may not be admitted to certified childcare unless

the child’s parent provides a statement from a physician that the child’s condition is no longer contagious or the

child has been absent for a period of time equal to the longest incuabation period for the disease as specified by

the Department of Health Services. I will report all communicable diseases to the local public health officer and to

parents of all enrolled children. Examples of communicable diseases include but are not limited to:

• Chicken Pox

• Mumps

• German Measles

• Scarlet Fever

• Infectious Hepatitis

• Meningitis

• Measles

• H1N1 Virus (swine flu)

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Substitute Care

 I will not be using a substitute. If I am not providing care for some reason (illness, vacation,etc.) you will

be required to find alternate care.

 I may use a substitute. The following individuals have been approved by 4-C to provide substitute care:

Substitute #1: ___________________________________________

Substitute #2: ___________________________________________

Sudden Infant Death Syndrome (SIDS):

According to certification standards, all providers, employees, substitutes and volunteers of a provider who provide

care and supervision for children under one year of age shall receive training in the most current medically accepted

methods of preventing sudden infant death syndrome (SIDS) before the date on which the provider is certified or

the employment or volunteer work commences.

 I have completed an approved SIDS training and am able to care for children under 1 year of age. I

completed the training on:________________. This can be verified with the 4-C office at 271-9181.

 I have not completed an approved SIDS training and can not care for children under 1 year of age until an

approved SIDS training has been completed.

To reduce the risk of SIDS I am required to place all infants under age 1 year on their backs to sleep, unless

otherwise instructed/directed in writing by the child’s physican. In additon, I am required to place all infants under

age 1 year to sleep in a safe crib or pack’n’play to nap.

Shaken Baby Syndrome (SBS):

According to certification standards, except for a volunteer who does no sole supervision of a child, all providers,

employees, substities, and volunteers of a provider who provider care and superivision of children under five years

of age shall receive department-approved training on shaken baby syndrome and impacted babies and approprate

ways to manage crying or fussing children.

 I have completed an approved SBS training and am able to care for children under 5 year of age. I

completed the training on:________________. This can be verified with the 4-C office at 271-9181.

 I have not completed an approved SBS training and can not care for children under 5 year of age until an

approved SBS training has been completed.

Guidance and Discipline:

(provider fills out)

My childcare will use the following methods to guide the child:_________________________________________

____________________________________________________________________________________________

The use of corporal punishment is strictly prohibited. I use guidance that will help each child develop self-control,

self-esteem, and respect for the rights of others. I will provide positive guidance and redirection, and will set clear

limits. If a timeout is used, it will not exceed 5 minutes. All guidance will be developmentally appropriate to the

age of the child.

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Additional Policies

Discrimination is prohibited in my daycare. I will not discriminate on the basis of race, color, sex, sexual

orientation, handicap or national origin or ancestry in accepting children or when hiring employees.

Please be aware that I am a mandatory reporter of child abuse and neglect. This means that if a child in my care has

been abused or neglected, or that child has been threatened with abuse, I will immediately inform the county social

or human services department and/or local law enforcement.

Additional Requirements:

(provider lists any additional items families need to provide)

 You are not responsible for additional requirements.

 You are responsible for the following additional requirements:

____________________________________________________________________________________________

Termination:

This contract may be terminated by either you or I by giving ______week written notice in advance.

• Should I terminate care:

You are/ are not

(provider circles) responsible for payment for all days your child is scheduled for care

during this time, regardless of whether or not your child is actually present.

• Should you terminate care:

You are/ are not

(provider circles) responsible for payment for all days your child is scheduled for care

during this time, regardless of whether or not your child is actually present.

Reasons for contract termination may include but are not limited to:

• Payments are not made.

• Required forms are not filled out in a timely manner.

• Your child’s needs are not met in my care.

• You do not abide by the signed contract.

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Should you have any questions or concerns, please notify me before signing this

contract. By signing, you hereby acknowlege that you have entered into a legally

binding contract. You also acknowlege that you have received and agree to abide by

the policies and procedures outlined. I may amend the contract by giving you a copy

of the new or changed policies at least ______weeks before any changes go into effect.

_______________________________________________ ______________

Parent/ Guardian’s signature Date

_______________________________________________ ______________

Parent/ Guardian’s signature Date

________________________________________________ ______________

Provider’s signature Date