
CHILD CARE SCHEDULE, PAYMENT & FEE AGREEMENT
I, ____________________________________ and __________________________________,
Parent or Guardian Parent or Guardian
agree to pay $ ______________ per _____________, due on _____________, for child care
as scheduled below to _______________________________.
Provider’s name
1) In the event my child or children are cared for at times additional to those scheduled, I agree
to pay an additional overtime charge per hour of $ ____________ due ___________________.
2) Additional fees agreed upon: Registration $_______________ per ______________
Activity/Material $___________ per _________ Deposit $__________for ________________
3) I understand I will be expected to pay the costs of regular child care whether my child or
children are in care or not to hold the slot(s) in my provider’s business. Yes/No, initial ________
4) This will include my and the provider’s vacation times. Yes/No, initial __________
5) This will include my child’s or family sick time. Yes/No, if yes initial __________
6) My provider agrees to give me _______________ notice before any change is made to
charges or fees, and will provide me with a new Agreement in the event of a change.
7) My provider agrees to give me _______________ notice for personal/vacation time.
Child Care Schedule:
Child #1 Name _________________________________
Days & hours ______________________________________________________
Child #2 Name __________________________________
Days & hours ______________________________________________________
Child #3 Name __________________________________
Days & hours ______________________________________________________
___________________________________ _________________________________
Parent’s Name Provider’s Name
___________________________________ _________________________________
Parent’s Signature Provider’s Signature
___________________ ___________________
Date Date
Child Care Resource Network a Program of The Job Council Word/LW/4-06