ART BARN CONTRACT 

This agreement is made by and between Rosemary Igoe Coyle, Licensed Child Care Provider and _______________________, Parent/Guardian of ________________. The following has been agreed upon between the two parties beginning _____________:

I am enrolling my child at Art Barn as of ____________.

Tuition to be paid on the first of the month in advance.

Art Barn is open Monday thru Friday from 8 00 am until 4 30 pm. Special accommodations can be made for families who need slightly different hours.    Arrival time and departure times are at the parents discretion with notice given to Miss Rose when possible.

These are the hours agreed upon:  arrival_______ departure_______ daily rate_____

Days my child will attend  M. T, W, TH, F (please circle)

Any added time before or after these hours will be discussed and negotiated beforehand.

Tuition to be paid on the first of the month in advance.

There are no refunds given for days missed and hours are only interchangeable if the schedule allows.

Art barn is open year round.   We are closed on Major holidays. Tuition is charged for holidays.  Miss Rose will take three weeks paid vacation over the course of the year and will provide ample notice of the dates. Miss Rose may take up to 3 paid sick/personal days, these will only be used in extreme circumstances.  Miss Rose will take up to three  days of bereavement when needed.   Miss Rose may take an additional week of unpaid vacation in Summer.  Make up days will be offered as the schedule allows.

A late fee of $25 dollars will be assessed after the 10th of the month

One Months nonrefundable deposit is required to hold a spot.  This shall be applied as last months tuition.  30 days notice is required to terminate contract.

This agreement shall be in effect until which time parent/guardian or provider has given termination notice in accordance to the Parent Handbook policy, or negotiation of a new contract.

___________________________________ ________________

Licensed Child Care Provider Date

BOTH PARENTS MUST SIGN OR PARENT/GUARDIAN WITH SOLE CUSTODY OF THE CHILD:

___________________________________ ________________

Parent/guardian Date

___________________________________ ________________

Parent/guardian Date

PERMISSION TO USE PHOTOS

You may/may not use my child’s photo in newsletters, on the website and on posters.  

________________________________________________

GENERAL INFORMATION

Date of admission_____  Date of discharge

Childs full name__________________   Date of Birth______________________

Address_________________________________City_______________ State_____zip____________

Telephone numbers______________________   ________________________

email address_____________________________________

PHYSICAL DESCRIPTION, PLEASE INCLUDE A RECENT PHOTO

eye color_______hair color___________ height_______________weight_____________sex_________

other distinguishing characteristics____________________

PARENT/GUARDIAN

name______________address_______________phone __________________email_______________

name_____________address________________phone__________________email________________

EMERGENCY CONTACTS (In order to be contacted) 

Name_______________________________________________________________________ Address_____________________________________________________________________

Relationship to child____________________________________________________________

Home Phone__________________________ Cell Phone______________________________

Do you give permission for child to be released to this person? Yes_____ No______

Name_______________________________________________________________________ Address_____________________________________________________________________

Relationship to child____________________________________________________________

Home Phone__________________________ Cell Phone______________________________

Do you give permission for child to be released to this person? Yes_____ No_____

Name_______________________________________________________________________ Address_____________________________________________________________________

Relationship to child____________________________________________________________

Home Phone__________________________ Cell Phone______________________________

Do you give permission for child to be released to this person? Yes_____ No___

TRANSPORTATION PLAN

Please specify the usual plan for drop off and pick up ___________________________________________________________________________________

DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION

CHILD’S NAME_______________________DATE OF BIRTH___________________

PERSONAL HISTORY

Any speech difficulties?__________________________________________________

Language spoken at home:_______________________________________________

Special words to describe needs:__________________________________________

HEALTH

Special physical conditions and disabilities: _________________________________

Allergies: ____________________________________________________________

Regular medications: ___________________________________________________

Covid -19

I acknowledge that by attending Child care at the time of this pandemic I assume all risk and responsibility for exposure.  I will in no way hold Art Barn responsible.

Please sign and date _____________________________    __________

Please sign and date acknowledge that you have read the letter to parents sent via email on June 24, 2020 regarding procedures relevant to Covid-19___________________________

___________

EATING HABITS

Describe favorite foods, foods refused, and any special characteristics: ____________

TOILET HABITS

How does child indicate bathroom needs include any special words): ______________

_____________________________________________________________________

SLEEPING HABITS

When does child get up in the morning: ___________and go to bed at night_________

Does child become tired or nap during the day?_______________________________

SOCIAL RELATIONSHIPS

How would you describe your child: ________________________________________

Previous experience with other children:_____________________________________

Reaction to strangers:_______________________ Able to play alone: ____________

Favorite toys and activities: _______________________________________________

_____________________________________________________________________

Fears (the dark, animals etc.):_____________________________________________

How do you comfort child: ________________________________________________

How do you discipline child: ______________________________________________

What would you like your child to gain from this experience?

Is there anything else you would like us to know about your child?

Parent’s signature___________________________  Date: _____________________

VISITS

Please sign to indicate that you are aware that you are welcome to visit Art Barn at any time your child is in my care.________________________

PARENT HANDBOOK 

Please sign to indicate that you have read and accept the terms of the Parent Handbook  __________________________________________________________________     date________________

MEDICAL EXAMINATIONS  

Evidence of a physical exam valid for one year from the date the child was examined and must be renewed annually thereafter.

Please provide documentation of a physical exam provided by your childs’  doctor including lead testing, and a record of immunizations.

FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM

Child’s Name: _______________________________ Date of Birth: ___________________

I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to ________________________, and to secure necessary medical treatment for my child.

Child’s Physician Name: ________________________________________________________

Address: ____________________________________________________________________

Phone Number: _______________________

Child’s Allergies: ______________________________________________________________

Chronic Health Conditions: ______________________________________________________

EMERGENCY CARD INFORMATION

Child’s Name: ______________________________Date of Birth_________________

Child’s Home Address: __________________________________________________

____________________________________ Phone # _________________________

Mobile Phone #________________________ E-mail___________________________

–INSTRUCTIONS TO REACH PARENT/GUARDIAN–

1.___________________________________________________________________

(Name, Address, Phone #)

2.___________________________________________________________________

(Name, Address, Phone #)

PEDIATRICIAN or SOURCE OF HEALTH CARE

1. ________________________________________________________________ (Doctor’s Name, Address, phone)

–MEDICAL EMERGENCY TREATMENT–

I hereby give   Art Barn preschool

permission to administer basic first aid and/or CPR to my child________________

(Name)

and/or take my child __________________, to a hospital for medical treatment

(Name)

when I cannot be reached or when delay would be dangerous to my child’s health.

_____________________________ __________________________

(Parent Signature)(Date)

Insurance Information (Optional)

Company Name:_____________________ Policy # ________________________

Participating Hospital: ________________________________________________

Special Instructions:_________________________________________________

EMERGENCY CARD INFORMATION ( duplicate necessary)

Child’s Name: ______________________________Date of Birth_________________

Child’s Home Address: __________________________________________________

____________________________________ Phone # _________________________

Mobile Phone #________________________ E-mail___________________________

–INSTRUCTIONS TO REACH PARENT/GUARDIAN–

1.___________________________________________________________________

(Name, Address, Phone #)

2.___________________________________________________________________

(Name, Address, Phone #)

PEDIATRICIAN or SOURCE OF HEALTH CARE

1. ________________________________________________________________ (Doctor’s Name, Address, phone)

–MEDICAL EMERGENCY TREATMENT–

I hereby give   Art Barn preschool

permission to administer basic first aid and/or CPR to my child________________

(Name)

and/or take my child __________________, to a hospital for medical treatment

(Name)

when I cannot be reached or when delay would be dangerous to my child’s health.

_____________________________ __________________________

(Parent Signature)(Date)

Insurance Information (Optional)

Company Name:_____________________ Policy # ________________________

Participating Hospital: ________________________________________________

Special Instructions:_________________________________________________