AGREEMENT

AGREEMENT

55 PA CODE CHAPTERS 3270.123 & 181 (C) 3280.123 & 181 (C)
NAME or CHILD
FEE AMOUNT $
DAY PAYMENTS TO BE MADE
MONDAY OR FIRST DAY OF ATTENDANCE
SERVICES TO BE PROVIDED AS PART OF THE DAYCARE FEE

Maximum of 8 hours (Full time) 5 hours (Part-time) of care per day (ELRC) (Private pay parents)

Phl-Pre-k students hours 8am 2:30pm

Adhere to drop off/Pick up times lisled below

Two week written notice of withdrawal
CHILD'S ARRIVAL & DEPATURE TIME
PERSON(S) DESIGNATED BY PARENT TO WHOM CHILD MAY BE RELEASED
LATE FEE

STARTS @ 10.00 FOR THE FIRST 15 MIN THEN $1/MIN AFTER THE FIRST 15 MINUTES
Extra services to be provided at an additional fee if applicable
RECEIVED COMPLETED WRITTEN PROGRAM INFORMATION AT THE TIME OF ENROLLMENT
3280.121 3290.12
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 OF PARENT
SIGNATURE OF OPERATOR
DATE

MonthDayYear
Date
DATE OF CHILD'S ADMISSION

MonthDayYear
Date
PERIODIC REVIEW
SIGNATURE

First NameLast Name
DATE

MonthDayYear
Date
DATE OF WITHDRAWAL

MonthDayYear
Date
Should be Empty: