Childcare Provider Service Acknowledgement Form
Please complete the Childcare Provider Service Acknowledgement Form to confirm your family's service agreement and operational details.
Child's Full Name
*
First Name
Last Name
Primary Guardian's Full Name
*
First Name
Last Name
Primary Guardian's Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Service Schedule
*
Please Select
Full-time (Monday–Friday, full day)
Part-time (Select days/times below)
Before/After School Only
Summer/Seasonal Care
Other
If part-time or other, please specify days and times
Emergency Pickup Contact Name
*
First Name
Last Name
Emergency Pickup Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
List all authorized pickup persons (full names separated by commas)
*
Does your child have any allergies or special needs the provider should be aware of?
*
No
Yes (please specify below)
By signing below, I acknowledge and agree to the operational details and service agreement as stated in the Childcare Provider Service Acknowledgement Form.
*
Submit Acknowledgement
Submit Acknowledgement
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