2017 CONTRACT-must be filled out for each child who attends Young-Uns

Young-Uns Preschool and Child Care Center

3375 Kennedy Circle

Dubuque, Iowa 52002 (563) 584-9285 – fax

(563) 584-0845 / –Deb

(563) 584-9284 / – Barb

Child’s Name: / Date of Birth:
Fears / Problems:

Gender / Male / Female / Allergies:(if allergies, please fill out careplan)
Sponsor (parent/guardian) / Co-Sponsor (parent/guardian)
Name: / Name:
Address: / Address:
City, State, Zip / City, State, Zip
Home Phone: / Home Phone:
Employer: / Employer:
Work Phone: / Work Phone:
Cell Phone: / Cell Phone:
Email: / Email:
Health Insurance Provider: / Health Insurance Number:

We, ______and ______sponsors of ______[Child’s name], do hereby give permission and/or consent to Young-Uns ChildCare Center, to secure and authorize emergency and medical or dental care and/or treatment as ______[Child’s name] might require underYoung-Uns supervision. I further authorize that the child’s provider may administer emergency care/treatment as required untilprofessional medical assistance is available. I also agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for ______[Child’s name] as secured or authorized under this consent.*NOTE: Every effort will be made to notify parents in case of emergency. In the event of an emergency, we will need the following information:

Doctor-must be filled in / Dentist-must be filled in / Hospital –must be filled in
Name:
Address:
Phone:

Has your child had a lead screen Yes/NoHas your child had a dental screening Yes/No

Sponsor Signature: ______Date: ______

Emergency Contact 1 / Emergency Contact 2
Name: / Name:
Address: / Address:
Phone / Phone:
Relationship: / Relationship:
Authorized Pick Up 1 / Authorized Pick Up 2
Name: / Name:
Address: / Address:
Phone / Phone:
Relationship: / Relationship:

Is anyone specifically denied permission to see your child? ______

(see parent access policy in parent handbook)(Official documentation must be provided)

School age children: My child attends ______school.

He/she needs Gus/Bess/Blue transportation: Morning: M T W TH F Afternoon: M T W TH F

FALL OF 2016 Pre-School age children: My child will attend ______school.

He/she will need Gus/Bess/Blue transportation: Morning: M T W TH FAfternoon: M T W TH F

Please initial each line next to questions 1-6 if permission is granted.

1. / I give permission for my child to have his/her picture taken at or in association with Young-uns.
2. / I give permission for my child to leave Young-Uns Child Care Center with supervision in a car, Young-uns vehicles or public transportation for pre-planned field trips. I understand that a certified seat belt will be used on all car and bus trips. If the Trolley or city bus is used, I understand seatbelts are not provided.
3. / Young-Uns also has permission to take my child off the premises for supervised walks. Do you have any restrictions on field trips? If so, please list: ______
4. / I give permission for my child to have sunscreen applied as often as needed. I understand that a sunscreen charge of $10.00/family will be added to my bill in April or May.
5. / My child does not have allergies to sunscreens.
6. / My child is allergic to ______Sunscreen. I will provide ______sunscreen.

Infants: All infants must pay the current full-time rate for infants. If you contract for 50 weeks of the year, two weeks of vacation will be allowed (full weeks at a time) that you do not have to pay for. If you sign the contract for under 52 weeks in a year, you will not be allowed vacation time off. If Young-uns is closed due to the holidays, then you will be charged for an average amount that you typically guarantee in a regular week. Meals are extra. All supplies are provided by the parent.

Parent of an infant please Initial one line below. (Example: teachers would mark the 2nd line)

I agree to pay for 50 weeks of childcare for the year. *See vacation time below*
I agree to pay for 40 consecutive weeks of childcare for the year. –no vacation time

Children 2-5: Must guarantee a minimum of 20 hours per week. If your child comes all year, you will be allowed 2 weeks of vacation. If your child only attends during the summer months, or only during the school year you will not get any weeks of vacation and must pay the minimum charge. Parent of a child 2-5: Please initial one line below.

I agree to pay for 50 weeks of childcare for the year. *See vacation time below*
I agree to pay for 40 consecutive weeks of childcare with a minimum of 20 hours/week-no vacation time

Kindergarten - School age Options:Parent of a school age child: please initial below

I agree to pay for before and after school care with a minimum charge during the school year.
I agree to pay for 11 consecutive weeks of childcare in the summer with a minimum of 20 hours/week.-no vacation
I agree to pay for 50 weeks with a 20 hour minimum in the summer. I will receive 2 weeks of vacation.
I agree to pay the drop in rate. My child will only come on scheduled non school days or early outs.
I understand that there is only 1 adult on the Young-uns bus to transport my child to and from school.
My school age child attends/or will attend:______school.
  • Vacation time is figured fromJanuary 1st-December 31st.
  • If your child begins June 1st or later, you will receive 1 week of vacation.
  • See current rate sheet for days Young-Uns will be closed due to holidays.

Standard Care / Hours Guaranteed: / Summer guarantee of hours
Monday Hours: / Monday Hours:
Tuesday Hours: / Tuesday Hours:
Wednesday Hours: / Wednesday Hours:
Thursday Hours: / Thursday Hours:
Friday Hours: / Friday Hours:
My guarantee of hours will fluctuate weekly. I agree to turn in a weekly guarantee of hours form by 12:00 on Tuesday.

Fees:See current Rate sheet

  • Standard fee payment is due: 1st day of the week that the child is at Young-Uns.
  • Hours attended outside of guaranteed hours: The computer will automatically charge you for hours that your child attends beyond your guaranteed hours. (For example, if you schedule from 8:00-4:00 and come 7:45-3:45, you will be charged 15 minutes-morning and nothing for the afternoon).
  • Termination of Agreement:

This contract can be terminated by the sponsor or co-sponsor by giving a 2 week advance notice. Payment for childcare services is due for the 2 week period, whether or not the child attends the child care program. The provider can terminate the contract immediately without giving any notice if parents or guardians do not make payments when they are due, or other situations have occurred-see handbook. The deposit is to be used for child care services only. There are no cash refunds.I/We agree to abide by the written terms of this contracted agreement.

Sponsor signature ______Date: ______