PROVIDER AND FAMILY AGREEMENT

Automatic Payment Choice*(Required)

CHILD INFORMATION SECTION

Name *Child 1(Required)
Name *Child 2
Name *Child 3
Name *Child 4

ACCOUNT AUTHORIZATION SECTION

I want to provide and authorize the following individuals to make changes to my account, including updating authorized pick-up persons, making financial decisions, and handling any other matters related to paperwork or the care of my child(ren). I will provide their names below. (Additional Parent, etc.)
Authorized Name 1
Authorized Name 2

SIGNATURE SECTION

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 parent/guardian a new copy of the policies at least two weeks before they go into effect.

Today's Date(Required)
I agree to this form(Required)
Name of Person Signing this Form
Clear Signature
This field is for validation purposes and should be left unchanged.