Sigmundian Daycare Contract

PARENT/GUARDIAN DAYCARE CONTRACT

I, ______________ (First Name), am sending my child, ____________ (First Name), to the daycare, Care for the gifted, for the amount shown at the end of this contract. The child is to attend the daycare on the weekdays of the period, _________________________________________, between hours 9AM to 5PM. I understand I may cancel at any time and that my money will be refunded in proportion to the days left (e.g. if a child leaves the daycare after attending 15 days of a 20-day program, the parent will be refunded 25% of their payment). This pro rata refund does not include absences (including sick days), late attendance, or leaving before the day is done. Child care can be terminated by either a guardian or the
provider at any time. A lunch is provided to the students and is included in the payment at the end of this contract.

Child’s full name: _______________________
Child’s DOB: ____-____-________

Your contact information:
Full name: ______________________
Street Address: ______________________
City, State, Zip: ______________________
Phone #: ______________________
Alternative #: ______________________
Email: ______________________

Other legal guardian contact information:
Full name: ______________________
Street Address: ______________________
City, State, Zip: ______________________
Phone #: ______________________
Alternative #: ______________________
Email: ______________________

Emergency contact (in the event a legal guardian cannot be reached):
Full name: ____________________
Phone #: ____________________

For routine communication, please contact me/the other legal guardian (circle one) by email.

List of any allergies of the child:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List of any medications taken by the child:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List of all medications the daycare will need to administer and instructions (attach if necessary):
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Initial below
I assert the following:
[ ]
I have listed all medical allergies of the child.
[ ]
I have listed all medication the child needs to take. If the daycare needs to administer such medication instructions will be given by me.
[ ]
I am the legal guardian of the child and I have the permission of any other legal guardians who have claim over the child to attend the daycare. Attending this daycare does not violate any court order or agreements made in any shared custody arrangements.
[ ]
My child is up to date on their vaccination shots. I have provided records of the following vaccinations:

Polio
Diphtheria, Tetanus, and Pertussis
(DTaP)
Haemophilus influenzae type b (Hib)
Measles, Mumps, and Rubella (MMR)
Hepatitis B (Hep B)
Varicella (Chickenpox)

[ ]
If my child contracts a communicable disease, he or she will not attend childcare until the disease is gone.
[ ]
I understand I am to provide a pen, a journal, and a Google Chromebook for my child to bring and leave at the daycare until the program is over.

The amount of $4,000 is to be paid in full before my child attends the daycare for the 20-day program.

Legal Guardian’s Full Name
(Print)

_________________________________

Signature Date

_________________________________ _____________________

Other Legal Guardian’s Full Name (Print)

_________________________________

Signature Date

_________________________________ _____________________

Daycare Provider’s Full Name (Print)

_________________________________

Signature Date

_________________________________ _____________________

Attention: Please be sure to obtain a copy of this signed contract for your records.