Wee Care Childcare, Inc.
Child & Family Information and Contract for Care
IMPORTANT, PLEASE READ BEFORE FILLING OUT THE FOLLOWING INFORMATION: If you are enrolling more than 1 child and any of the information is different, such as physician, dentist, emergency contacts, authorization for pick-up person(s), medical insurance information, and/or contracted days/hours please fill out a separate form for each child, listing them as child # 2, child # 3, etc.
Children's Information
Child # 1 Information*
First Name Last Name
Date of Birth*
Month Day Year
Date
Gender*
Male Female
Primary Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date of enrollment*
Month Day Year
Date
Days needing care:*
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Child Care Drop-Off Time
: Hour Minutes AM/PM Option
Chlld Care Pick-Up Time
: Hour Minutes AM/PM Option
School Drop-Off Time (earliest time they can be on campus)
: Hour Minutes AM/PM Option
School Pick-Up Time
: Hour Minutes AM/PM Option
* Weekend care and/or before/after hours will need to be approved by me in advance.
** Filling in the days/hours you need care does not guarantee I can take your child any particular days/hours. I will do my best to accommodate everyone's schedule.
Name of School
Address of School
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number of School
Area Code Phone Number
Please enter any information about your child that would be helpful for me to know (including any allergies, medical conditions, and/or special needs they may have):
Child #2 Information
First Name Last Name
Date of Birth
Month Day Year
Date
Gender
Male Female
Primary Address (if different than child #1)
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date of enrollment
Month Day Year
Date
Days needing care:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Child Care Drop-Off Time
: Hour Minutes AM/PM Option
Child Care Pick-Up Time
: Hour Minutes AM/PM Option
School Drop-Off Time (earliest time they can be on campus)
: Hour Minutes AM/PM Option
School Pick-Up Time
: Hour Minutes AM/PM Option
* Weekend care and/or before/after hours will need to be approved by me in advance.
** Filling in the days/hours you need care does not guarantee I can take your child any particular days/hours. I will do my best to accommodate everyone's schedule.
Name of School
Address of School
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number of School
Area Code Phone Number
Please enter any information about your child that would be helpful for me to know (including any allergies, medical conditions, and/or special needs they may have):
Child # 3 Information
First Name Last Name
Date of Birth
Month Day Year
Date
Gender
Male Female
Primary Address (if different than child #1)
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date of enrollment
Month Day Year
Date
Days needing care:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Child Care Drop-Off Time
: Hour Minutes AM/PM Option
Child Care Pick-Up Time
: Hour Minutes AM/PM Option
School Drop-Off Time (earliest time they can be on campus)
: Hour Minutes AM/PM Option
School Pick-Up Time
: Hour Minutes AM/PM Option
* Weekend care and/or before/after hours will need to be approved by me in advance.
** Filling in the days/hours you need care does not guarantee I can take your child any particular days/hours. I will do my best to accommodate everyone's schedule.
Name of School
Address of School
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number of School
Area Code Phone Number
Please enter any information about your child that would be helpful for me to know (including any allergies, medical conditions, and/or special needs they may have):
Child # 4 Information
First Name Last Name
Date of Birth
Month Day Year
Date
Gender
Male Female
Primary Address (if different than child #1)
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date of enrollment
Month Day Year
Date
Days needing care:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Child Care Drop-Off Time
: Hour Minutes AM/PM Option
Child Care Pick-Up Time
: Hour Minutes AM/PM Option
School Drop-Off Time (earliest time they can be on campus)
: Hour Minutes AM/PM Option
School Pick-Up Time
: Hour Minutes AM/PM Option
* Weekend care and/or before/after hours will need to be approved by me in advance.
** Filling in the days/hours you need care does not guarantee I can take your child any particular days/hours. I will do my best to accommodate everyone's schedule.
Name of School
Address of School
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number of School
Area Code Phone Number
Please enter any information about your child that would be helpful for me to know (including any allergies, medical conditions, and/or special needs they may have):
Child # 5 Information
First Name Last Name
Date of Birth
Month Day Year
Date
Gender
Male Female
Primary Address (if different than child #1)
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date of Enrollment
Month Day Year
Date
Days Needing Care:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Child Care Drop-Off Time
: Hour Minutes AM/PM Option
Child Care Pick-Up Time
: Hour Minutes AM/PM Option
School Drop-Off Time (earliest they can be on campus)
: Hour Minutes AM/PM Option
School Pick-Up Time
: Hour Minutes AM/PM Option
* Weekend care and/or before/after hours will need to be approved by me in advance.
** Filling in the days/hours you need care does not guarantee I can take your child any particular days/hours. I will do my best to accommodate everyone's schedule.
Name of School
Address of School
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number of School
Area Code Phone Number
Please enter any information about your child that would be helpful for me to know (including any allergies, medical conditions, and/or special needs they may have):
Parent/Guardian Information
Parent/Guardian # 1 Information:*
First Name Last Name
Relationship to child*
Home Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Cell Phone Number*
Area Code Phone Number
Email Address
example@example.com
Name of Employer*
Work Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Work Phone Number*
Area Code Phone Number
Work Email Address
example@example.com
Any special instructions for reaching you while your child is in care:*
Parent/Guardian #2 Information:
First Name Last Name
Relationship to child
Home Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Cell Phone Number
Area Code Phone Number
Email Address
example@example.com
Employer Name
Work Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Work Phone Number
Area Code Phone Number
Work Email Address
example@example.com
Any special instructions for reaching you while your child is in care:
Other person(s) living in the home
This is required by CDHS. You do not need to list any parent and/or child that is listed on the information sheet.
Name of person # 1
First Name Last Name
Date of Birth
Month Day Year
Date
Relationship to child
Phone Number
Area Code Phone Number
Person # 2 Information:
First Name Last Name
Date of Birth
Month Day Year
Date
Relationship to child
Phone Number
Area Code Phone Number
Person # 3 Information:
First Name Last Name
Date of Birth
Month Day Year
Date
Relationship to child
Phone Number
Area Code Phone Number
Authorization for Pick-Up Person(s)
Any person(s) listed below will be allowed to pick-up your child with no additional authorization needed. They will be asked to show a picfture ID. They will be required to sign the child out. It is your sole responsibility to make changes as needed.
Name of pick up person # 1:
First Name Last Name
Relationship to child
Address of pick-up person # 1
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number of pick-up person # 1
Area Code Phone Number
Name of pick-up person # 2
First Name Last Name
Relationship to child
Address of pick-up person # 2
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number of pick-up person # 2
Area Code Phone Number
Name of pick-up person # 3
First Name Last Name
Relationship to child
Address of pick-up person # 3
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number of pick-up person # 3
Area Code Phone Number
Emergency Contacts
These will be used if the parent/guardian cannot be reached in an emergency. If these are also authorized pick-up person(s), please still list them under Person(s) Authorized for Pick-Up.
Emergency Contact # 1:*
First Name Last Name
Relationship to child*
Home Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Cell Phone Number*
Area Code Phone Number
Email Address
example@example.com
Emergency Contact # 2:
First Name Last Name
Relationship to child
Home Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Cell Phone Number
Area Code Phone Number
Email Address
example@example.com
Medical, Dental, and Health Insurance Information
The health Insurance information will only be used If there is a medical emergency and they are taken to a medical facility.
Medical Facility Name
Physician's Name*
First Name Last Name
Physician's Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Physician's Phone Number*
Area Code Phone Number
Physician's FAX Number
Area Code Phone Number
Physician's Email Address
example@example.com
Dental Facility Name
Dentist's Name*
First Name Last Name
Dentist's Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Dentist's Phone Number*
Area Code Phone Number
Dentist's Email Address
example@example.com
Local Hospital of Choice (in case your child has an emergency):*
Name of hospital
Hospital Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Hospital Phone Number*
Area Code Phone Number
Insurance Company Name
Insurance Company Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Insurance Company Phone
Area Code Phone Number
Insurance Company Email
example@example.com
Policy Number
Policy Holder's Name
If you, or any family members do not have medical and/or dental insurance and/or a medical home you can obtain information at www.connectforhealth.com or by calling (855)752-6749. I can also help you to find other resources and referrals.
Wee Care Childcare, Inc. Contract for childcare
Rates are on a case-by-case basis depending on your child's age, how many children you are enrolling in my care, and days & hours needing care.
If your child has special needs requiring extra care the rate will be based on the level of additional care needed.
Please refer to my Policies and Procedures for a list of additional rates and fees.
Each child has their own contracted days and times and enrollment is based on my availability for those contracted days and times. Once the schedule is agreed upon by both parties, those will be your child's contracted days and times for care. Just because I am open earlier or close later than the contracted times DOES NOT mean that you can bring your child early or leave them late! If you do, you will be charged the early drop-off/late pick-up fee as listed on the fee schedule listed in my Policies and Procedures. If you are needing to change your child's contracted days and/or hours please let me know and I will do my best to accommodate the change.
If any changes need to be made you will be emailed another Information and Contract for care forms. It is your sole responsibility to make changes as they arise.

By signing below you are acknowledging and agreeing to the above statements.
Entering my name below will serve as my electronic signature.*
Please type you full name in box above
Date*
Month Day Year
Date
This form was amended on 9/24/20
Should be Empty:

Wee Care Childcare, Inc.

Children's Information

Parent/Guardian Information

Other person(s) living in the home

Authorization for Pick-Up Person(s)

Emergency Contacts

Medical, Dental, and Health Insurance Information

Wee Care Childcare, Inc. Contract for childcare