2010 Contracts

Pumpkin Patch Daycare

The Home Front Contract

This contract is an agreement between:

___________________________ & Ashley Hartung (Pumpkin Patch Daycare)

To provide care for:

______________________________________________________________

This contract will be in effect from __________ to January 15th 2011.

There will be a 2 calendar week trial period in which either party may end this agreement, for any reason. Any fees paid will not be refunded should this occur. This does not apply to yearly renewal contracts.

This contract is a first time contract/yearly renewal – circle one.

Rates and rules for payment are outlined in the Pumpkin Patch Daycare Handbook; Please do not sign this contract until you have read all rules regarding rates and late fees, etc.



It is agreed that schedules will be made by Friday for the following week. Payments are due on Fridays by 5:30 PM for the following week, according to this schedule.



This contract is simple, as all rules are outlined in my parent handbook and agreed upon and followed as part of this contract:

I have received a copy of the Pumpkin Patch Daycare Handbook and agree: __________ (initials)

Permanently enrolled families will receive their own copy or you may also view a copy at Pumpkin Patch Daycare.

Parents Name:_____________________________________________________________

Parents Signature:__________________________________________________________

Date:_____________________________________________________________________

Provider Name: Ashley Hartung, Pumpkin Patch Daycare

Provider Signature:_________________________________________________________



Registration Form

Child’s Full Name:______________________________________________________________________

Birthdate:__________________________________ Nickname(s):____________________________

Home Address:________________________________________________________________________

Home Phone:__________________________________________________________________________

Email Address (for pictures and updates):___________________________________________________

Mothers Name:_____________________________ Occupation:_____________________________

Place of Employment:________________________ Length of Employment:____________________

Work Phone:_______________________________ Cell Phone:__________________Text?_______

Fathers Name:______________________________ Occupation:_____________________________

Place of Employment:________________________ Length of Employment:____________________

Work Phone:_______________________________ Cell Phone:___________________Text?______

Parent/Guardian with legal custody:_______________________________________________________

Parents are: Married/Divorced/Separated/Single

*If parents are separated or divorced, please indicate whether the other parents has permission to have contact with the child at Pumpkin Patch Daycare and whether or not he/she is allowed to pick up the child. If there is a no contact order for the non custodial parent I will need to have a copy of the paper work.

Contact: Yes/No/Not Applicable Pick Up: Yes/No/Not Applicable

Emergency Contact Person in addition to parents. (They must be within a 20 mile radius of Spearfish.) Name/Relationship _______________________________________ Phone ________________________ Name/Relationship _______________________________________ Phone ________________________ Name/Relationship _______________________________________ Phone ________________________

Other than you, who has permission to pick up your child? Any person not listed will not be allowed access to your child. Anyone other than the parents will be required to show photo identification at pick up. Anyone (including parents) should have proper child restraints for transportation. Name/Relationship _______________________________________ Phone ________________________ Name/Relationship _______________________________________ Phone ________________________ Name/Relationship _______________________________________ Phone ________________________ Name/Relationship _______________________________________ Phone ________________________



About Your Child

1. What foods does your child especially like?___________________________________________

2. Especially dislike?________________________________________________________________

3. Child’s usual dining habits: Highchair/Table/Uses Utensils/Bottle/Sippie Cup/Regular Cup

4. Does your child have a small or large appetite?________________________________________

5. Breakfast is served at 8:00 am, will your child eat breakfast before coming to Pumpkin Patch Daycare? Yes/No

6. If your child is drinking formula, do they prefer it: Warm/Room Temp/Cool

7. Favorite toys, games, activities?____________________________________________________

8. Is your child potty trained?________________________________________________________

9. We use ‘potty’, ‘tinkle’, & ‘stinky’ at Pumpkin Patch Daycare, it would be helpful if while training your child you used the same terms.

10. Do you wish me to help them with potty training while here? Yes/No

11. How would you describe your child’s personality?______________________________________

12. How does your child express anger or frustration?______________________________________

13. Does your child have any special fears?_______________________________________________

14. When your child is upset, what helps to comfort him/her?_______________________________

15. How do you DISCIPLINE your child?__________________________________________________

16. Has your child been taking a morning nap? Yes/No If so, how long?____________________

Afternoon nap? Yes/No If so, how long?____________________

17. Special toy or blanket for nap?_____________________________________________________

18. What is your child’s disposition when waking up?______________________________________

19. Special family situations? (such as custody specifications, problems arising for situations, etc?)___________________________________________________________________________________________

20. Anticipated adjustment problems?__________________________________________________

21. Any disorders/developmental (slow or advanced) diagnosed or suspected? ______________________________________________________________________________

22. Previous daycare child has attended?________________________________________________

Dates? From:__________ To:__________

Phone:_____________________________

Contact: Yes/No

23. Why was care terminated?________________________________________________________

24. Any problems at previous daycares?_________________________________________________

25. Expectations of Pumpkin Patch Daycare:___________________________________________________

26. Other comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Health History

1. Last Physical Exam:_______________________________________________________________

2. Does your child need regular medications for a health problem? Yes/No

If yes; what, when, and how is it given:________________________________________

*Please sign the permission forms, authorizing Ashley Hartung (Pumpkin Patch Daycare) to administer the medication needed.

Illnesses: (please circle if your child has [or has had] any of those listed)

Constipation Convulsions

Diarrhea Fainting Spells

Frequent Colds Frequent Ear Infections

Frequent Sore Throats Lice

Ringworm Skin Rash

Soiling/Smearing Worms

Urinary Problem Asthma

Bronchitis Chicken Pox

Diabetes Heart Disease

Hepatitis Measles

Mumps German Measles

Polio Scarlet Fever

Tuberculosis Whooping Cough

Sleep Apnea Night Terrors

Sleep Walks



3. Other illnesses? (besides above):____________________________________________________

4. Has your child been hospitalized: (explain) ___________________________________________

5. Has your child had injuries with fractures or loss of consciousness? (explain) ________________

6. Last Vision test:_______________ OK?_______________

Last hearing test:_______________ OK?_______________

Last dentist visit:_______________ OK? _______________

7. Any other members of your family with serious illness recently?__________________________

8. Any other members of your family with history of:

Asthma: Yes/No Diabetes: Yes/No Epilepsy: Yes/No

9. Any allergies? Yes/No List:_______________________________________________________

Special instructions in the event of an allergic reaction:_____________________________________

10. Does your child have any mental or physical disabilities? Yes/No _________________________



Parents Name: _____________________________________________

_____________________________________________

Parents Signature: _______________________________________

_______________________________________

Date: ______________________________________________________

Provider: Ashley Hartung, Pumpkin Patch Daycare

Provider Signature: __________________________________________

Date: ______________________________________________________



































Permissions

MEDICINE (Over the Counter)

Ashley Hartung (Pumpkin Patch Daycare) has my permission to administer over the counter type medication (Tylenol, Dimetapp, Diaper Rash Ointment, Sun Block, etc.) to my minor child.

Child’s Name:__________________________________________________________________________

Parent/Guardian Signature:______________________________________________________________

Date:_________________________________________________________________________________

MEDICINE (Prescription)

Ashley Hartung (Pumpkin Patch Daycare) has my permission to administer Prescription medication to my minor child. Prescription should be in the original container with the child’s name, date prescribed, and dosage on the label.

Child’s Name:__________________________________________________________________________

Prescription:___________________________________________________________________________

When & How to take prescription:_________________________________________________________



Parent/Guardian Signature:______________________________________________________________

Date:________________________________________________________________________________

Trips

Ashley Hartung (Pumpkin Patch Daycare) has my permission to transport my minor child in her private vehicle. Trips will not be out of the Spearfish area without further permissions, and each child will be in the appropriate care restraint.

Child’s Name:__________________________________________________________________________

Parent/Guardian Signature:______________________________________________________________

Date:_________________________________________________________________________________

General

Ashley Hartung (Pumpkin Patch Daycare) has my permission to:

Take my child on a walk? Yes/No Take my child swimming: Yes/No

Take Photos of my child: Yes/No Put photos on Pumpkin Patch Daycare blog: Yes/No

Give an occasional candy treat? Yes/No Assist child with potty training? Yes/No/Not App.

Child’s Name:_________________________________________________________________________

Parent/Guardian Signature:______________________________________________________________

Date:________________________________________________________________________________

Permissions



Medical Care

Ashley Hartung (Pumpkin Patch Daycare) has my permission to seek and obtain emergency medical, dental, or surgical treatment as prescribed by a treating physician for my minor child. I give my permission for my child to be transported by care or ambulance to and emergency center for treatment.

Full Name of Minor:_____________________________________________________________________

Birth Date:____________________________________________________________________________

Allergies to Med.:______________________________________________________________________

Special Health Problems:_________________________________________________________________

Regular Medications:____________________________________________________________________

Blood Type:___________________________________________________________________________

Name of Doctor:_______________________________________________________________________

Name of Insurance Co.:__________________________________________________________________

Member/Policy Number:_________________________________________________________________

On record at Spearfish regional Medical Center: Yes/No

Name of Policy Holder:__________________________________________________________________

Pumpkin Patch 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 Ashley Hartung and Pumpkin Patch 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, whether such claims are known or unknown or arise in the future.

Parent/Guardian Signature:______________________________________________________________

Date:_________________________________________________________________________________