Child Care Agreement Form - Washington
10.9.2.9 Child Care Agreement
Rev. 10/10
Child Care Agreement
First Middle Last
Child’s name:
First Middle Last
Parent or guardian name:
First Middle Last
Parent or guardian name:
Days and times my child will receive care:
Check days of
care
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Arrival time
Departure time
Fee: $ per:
Hour Day Week Month
Date payment due:
Source of payment: Parent Other (specify):
Overtime rate: $ per
Late fee: $ per
Other Fees: $ Description:
I agree to promptly notify the child care provider of any changes of the above information. I understand that I am fully
responsible for the terms of this agreement as stipulated.
I have read, understand and agree to comply with the policy and procedures and information for parents given to me by
________________________
Name of licensee
Parent or guardian signature
Date
Parent or guardian signature
Date
I agree to provide child care services according to the above plan. I agree to promptly notify the parents or guardians of any
changes to above information.
Licensee signature
Date
Street address City State Zip code
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