Multiple Payer Form

Multiple Payer Form Confidential

Parent Name(Required)

First Name Last Name

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number 1(Required)

Employer Name(Required)

Work Phone(Required)

Email Address(Required)

Child 1 Name(Required)

Child 1 date of birth(Required)

Child 2 Name

Child 2 date of birth

Child 3 Name

Child 3 date of birth

You understand that you will receive an invoice each month by the first Friday of the month and agree to pay the invoice total. You understand that you are not the main account holder, and your invoice will not be itemized. If you want a copy of the itemized invoice, you will need to speak with the main account holder. You understand that you are paying for half of the child care charges. You understand that you will need to pay the invoice by the first Friday of each month and if the payment is missed, you will receive a $25 late fee. Then you will have until the third Friday of the month to pay the full balance, otherwise, the charges on your invoice will be applied to the main account holder's account and you will not be able to have a separate account.

By signing below, I agree to all terms of this contract and acknowledge that I have received or have access to through the center's website, a copy of all policies and procedures. This contract is subject to renewal. The provider may amend the policies by giving the parents a new copy of the policies at least two weeks before they go into effect. The person signing this form, is responsible to pay the "other" ledger if the account.

Electronic Signature(Required)

Today's Date(Required)

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