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Attendance Agreement Form - DOC

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Attendance Agreement Form - DOC Powered By Docstoc
					       EARLY LEARNING CENTER SCHEDULE AGREEMENT FORM

Child’s Name_________________________________________

Parent/Guardian Name_________________________________

Date________                      Student ID Number___________________

Category (check one): Student______            Staff/faculty_____      Community______

Semester (circle one):        Fall ___         Spring___

Indicate schedule of days and times needed for child care by entering the exact time
you plan to leave and pick up your child. This schedule is used to determine the set
weekly fee you will be charged, regardless of child’s attendance.

                         IN              OUT            IN             OUT       TOTAL
Monday

Tuesday

Wednesday

Thursday

      TOTAL



My weekly fee for services is: $_____________________. (see fee schedule on back)
Name of individual(s) or agency responsible for payment (i.e. self, other third party,
Choices –with a valid certificate): ____________________________.


I understand this amount of payment is expected to be paid in full according to the
agreed upon payment schedule whether my child is in attendance or not. My payment
will be adjusted to reflect additional hours if more hours are used than scheduled.


__________________________________                           _______________________
(Parent/Legal Guardian Signature)                             (Date)



__________________________________                           _______________________
(Director or other authorized Children’s                      (Date)
 Room Personnel Signature)

                                                                               (OVER-)

Revised 6-1-09
The following fee schedule is used to determine the weekly fee you will be cha rged.


                                   Students        Staff/Faculty      Community

Up to 10 hours per week            $40             $45                $50

10 hours – 20 hours per week       $70             $75                $80

20 hours and over per week         $90             $100               $110

Hourly                             $4.50           $5.50              n/a

Registration fee per semester      $5              $5                 $20




Revised 6-1-09

				
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