Name of Child
Day payment to be made
Services to be provided as part of the day care fee (examples; transportation, care, meal, etc.)
Person(s) designated by parent to whom child may be released
Extra services to be provided at an additional 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 minimum. (§ 3270.124, 3280.124, 3290.124)
Signature
Parent Signature Date
Please leave this field empty.
