Nora’s Daycare             Parent - Provider Agreement
Nora Gross
2304 Turner
Lansing, MI 48906-4059
517-485-4427

I, Nora Gross, agree to provide childcare, as outlined in Nora’s Daycare Parents Handbook, for_________________________________  on behalf of ___________________________________ on the following terms and conditions:
Scheduled childcare time:   
MON   ___________  to  __________    
TUE    ___________  to  __________  
WED   ___________  to  __________                               
THU    ___________  to  __________                                
FRI      ___________  to  __________                                
Childcare services rate will be $120.00 per week.  Payment is due MONDAY, (or Tuesday, if Monday is a holiday) before services are rendered.  If your child is in attendance more than your scheduled time, additional hours will be billed at $3.00 per  hour.
A $10 per day fee will be charged on all late payments.
Nora’s Daycare is entitled to the above fee even if the child is not present due to illness, holidays, etc. I will notify you of any change in my childcare fees 30 days before the new rate goes into effect.
  
Holidays and 
Nora’s Daycare will be closed for the following holidays and payment is required for these days:  New Years Day;  Memorial Day;  Independence Day;  Labor Day; 
Thanksgiving & the day after;  Christmas, and Christmas Eve.
This will also include any Friday that follows a Thursday holiday, or a Monday that precedes a Tuesday Holiday, in which the majority of people have the day off.

Vacation Days
You will be allowed ten vacation days within the calendar year. 
You will not be charged for your vacation days, and you may use them as needed.
You will not be charged for my vacation days, as I will be closed. 

Child’s Full Name ________________________________________________________       
Birth Date ______________________
Address ________________________________________________________________ 
City ___________________________________  State _____  Zip Code _____________

Mother’s Full Name _______________________________________________________      
Address ________________________________________________________________ 
City ___________________________________  State _____  Zip Code _____________
Home Phone  ________________________   Cell Phone  _________________________
Employer __________________________________   Work Phone _________________ 
Business Address _________________________________________________________
Work Hours _____________________________________________________________  

Father’s Full Name ________________________________________________________
Address ________________________________________________________________ 
City ___________________________________  State _____  Zip Code _____________
Home Phone  ________________________   Cell Phone  _________________________
Employer __________________________________   Work Phone _________________ 
Business Address _________________________________________________________
Work Hours _____________________________________________________________ 
 
Parent/Guardian with legal custody _____________________________________________________________
Note: copies of legal documents must be provided if one parent is not allowed to have contact with the child.

Primary Emergency Contact  (Within 20 mile radius of daycare other than parent or guardian)
________________________________________________________________________
Home Phone ________________________  Work Phone__________________________
Relationship to Child ______________________________________________________
Address ________________________________________________________________

Secondary Emergency Contact (Within 20 mile radius of daycare other than parent or guardian)
________________________________________________________________________
Home Phone ________________________  Work Phone__________________________
Relationship to Child ______________________________________________________
Address ________________________________________________________________

Person(s) authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
________________________________________________________________________
________________________________________________________________________
Person (s)  NOT authorized to pick up my child: (Besides parents, guardians, or emergency pick ups)
 _______________________________________________________________________
________________________________________________________________________
Emergency Information

1. Physician ___________________________________   Phone____________________
2. Hospital: ___________________________________  Phone ____________________
3. Insurance  ___________________________   Policy #  _________________________
4. Regular Medications_____________________________________________________
5. Blood Type  ____________________________________
6. Medicine allergic to _____________________________________________________
7. Food Allergies  _________________________________________________________
8. Any other Allergies  _____________________________________________________
9. Any special health conditions _____________________________________________

The Licensee, Edward J. Gross & Nora I. Gross, State of Michigan license number DG330094359, shall herein be named “Nora’s Daycare” for any legal purposes. This name will also include any current employees and/or volunteer assistants under direct supervision

Disclaimer
Nora‘s Daycare, shall not be responsible for providing or paying for the child’s health care. 
I agree that neither I or my child will bring any claims of any kind against  Nora’s Daycare  as a result of any injuries, expenses or damages that I or my child may suffer in any way related to the use of our facilities, toys, other children, teachers, whether such claims are known or unknown or arise in the future. 
Parent’s Signature __________________________________  Date  _________________

Consent to Emergency First Aid & Transportation
I hereby give permission to Nora’s Daycare to provide emergency treatment  to my child, as needed.  
I also give permission for my child to be transported by car, ambulance, or aid car to an emergency center for treatment. 
I hereby expressly waive any claim for injury or damage to such child arising out of such care, treatment & transportation, and expressly agree to hold  Nora’s Daycare harmless.
Parent’s Signature __________________________________  Date  _________________

Consent to Medical Care and Treatment
In the event that I cannot be contacted immediately, medical of surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician. 
I hereby expressly waive any claim for injury or damage to such child arising out of such care and treatment and expressly agree to hold  Nora’s Daycare harmless.
Parent’s Signature __________________________________  Date  _________________

Field Trip Permission
I hereby give permission to Nora’s Daycare to allow my child to participate in field trips, go to the park, or any other activities that would involve taking the child outside of the daycare for his/her benefit in attendance at this facility.
I hereby expressly waive any claim for injury or damage to such child arising out of such field trip and expressly agree to hold  Nora’s Daycare harmless.
Parent’s Signature __________________________________  Date  _________________
Lotion & Bug Repellant Permission
I hereby give permission to Nora’s Daycare to apply sun block lotion and/or bug repellant spray or lotion to my child as needed. 
I hereby expressly waive any claim for injury or damage to such child arising out of such application and expressly agree to hold  Nora’s Daycare harmless.
Parent’s Signature __________________________________  Date  _________________

Termination Procedure by Provider
The first four weeks of your child's attendance at Nora’s Daycare will be on a trial basis. 
At any time after the adjustment period, Nora’s Daycare may choose to terminate this agreement without cause by issuing verbal notice. The termination date will be two weeks from that day, to allow you to find a different childcare facility. You are responsible for childcare fees up to the termination date.
Any failure of the parent to abide to this contract will result in an immediate termination notice.
The termination date shall be 24 hours after the parent has received the notice.
This will be for cause such as, but not limited to: 
(a) Failure to pay childcare fees. 
(b) Failure of child or parent to refrain from violent behavior. 
(c) Failure of parent to drop off and pick up child at scheduled hours. 
(d) Failure of parent to refrain from bringing an ill child to my home.

Termination Procedure by Parent
If your work situation changes, or if you are not satisfied with the services provided, You may terminate this agreement at any time. Any unpaid child care fees are considered due. Any previously paid childcare fees will NOT be refunded. 
It would be appreciated if you could let me know at least two weeks in advance of your last day. I normally have a waiting list, and this will give me time to fill your vacated position. 

Illness/Emergency Procedures
If I am unable to care for your child due to my illness or emergency, you shall be notified. You will be responsible for seeking alternate childcare. On occasion, a substitute may be available at my home, and I will notify you when this occurs. I suggest that you pre-arrange alternate childcare as a back up. There shall be no charge for childcare that is not actually provided due to my emergency. Fees shall be credited on a prorated basis.
Children attending Nora’s Daycare must be able to participate in the daily events. If medication or illness prevents them from participating, please keep them home. If a child becomes ill while at Nora’s Daycare, I will isolate them from the others and contact you as soon as possible. You will be responsible to pick up the child as quickly as possible. I will expect someone within 1 hour.
Illness, medication management, and health information policies as stated in 
Nora’s Daycare Parent Handbook  will be followed as written.

	

Agreement
I/we have read, understand, and agree to all rates, policies, and procedures, as outlined in 
Nora’s Daycare Parent Handbook
I/we have accurately filled out all required enrollment forms presented to me.
I/we have read this contract and will comply with all provisions contained herein, and shall at this time enter into agreement with NORA GROSS for the care of my/our child with the understanding that we shall work together on behalf of the child.
This agreement is in effect until a change is mutually agreed upon in writing or upon termination of care.
This agreement is subject to review and renewal one year from effective date. 
Any changes made by the provider to the terms of the agreement must be made on the renewal date unless mutually agreed to beforehand by the provider and parents who are parties to this agreement. otherwise, this agreement will remain in effect until the renewal date or upon termination of care as set forth herein.

Parent’s Signature __________________________________  Date  _________________
I understand this is a legally binding contract, and I have read it and understand it.
Legal Address  __________________________________________________________

Parent’s Signature __________________________________  Date  _________________
I understand this is a legally binding contract, and I have read it and understand it.
Legal Address ___________________________________________________________

The information supplied above will be held in confidence, unless required for emergency situation.
Any changes to information are the responsibility of the Parent to provide.
By signing this I attest that all information is correct and accurate, and that I am responsible for payment of any child care fees, and any medical and/or emergency costs incurred by my child.

I, NORA GROSS. have discussed and reviewed this contract with one or both parents, and agree to provide  care for their child(ren) in my home, as long as the terms of the contract are upheld.

Provider’s Signature  ____________________________________  Date  ____________

Legal address   2304 Turner   Lansing, Mi.   48906