Agreement Agreement 55 PA CODE CHAPTERS 3270.123 & 181(C); 3280.123 & 181(c); 3290.123 & 181(c) Your Email Address* Your Name* First Last Name of child* First Last Fee Amount* PER-DAY-WEEK: Week DATE PAYMENT TO BE MADE: Monday by 6pm Services to be provided as part of the day care fee. Examples: transportation, care, meals, etc. In addition to meeting the daily needs of the children (Diapering, aid with eating, sharing, manners), we are a we are a "hands on" learning that introduces colors, shapes, numbers, and general academic material through various methods. For example: arts and crafts, activities, circle time, story time, outside play, structured group play, and various learning activities. We focus on the social and emotional development of the child. We also provide all meals. For additional information, please see your Parent Handbook. Maximum of 10 hours of care per day. All copayments/tuition payments are due when students are absent. CHILD'S ARRIVAL TIME* : Hours Minutes AM PM AM/PM CHILD'S DEPARTURE TIME* : Hours Minutes AM PM AM/PM PERSON(S) DESIGNATED BY PARENT TO WHOM CHILD MAY BE RELEASED* Late Fee: $1.00 Per Min-Hr: Minute Extra services to be provided at an additional fee, if applicable: Tips and special events, Transportation. Date of child's admission MM slash DD slash YYYY Date of child's withdrawal MM slash DD slash YYYY I, the parent/guardian* Received complete written program information at the time of enrollment. (3270.121, 3280.121, 3290.121)I, the parent/guardian* 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)Digital signature of operator*SignatureToday's DateBy typing my name in this field, I am providing my digital signature to this form. Digital signature of parent or guardian*SignatureToday's DateBy typing my name in this field, I am providing my digital signature to this form. Digital signature of parent or guardian for Periodic Review*SignatureToday's DateBy typing my name in this field, I am providing my digital signature to this form. CommentsThis field is for validation purposes and should be left unchanged.
