DCFS FORM
LATE PICK-UP AGREEMENT
The following agreement is made between ______________________and_________________________
Parents/Guardians Provider
____________for the pick-up of their child/children ___________________, ______________________
Name name name
____________________, __________________, _ _______________ from the day care — home/group.
Name name name
I/we agree to pick up the above named child/children before ____________ he/she/they are in child care o'clock p.m. every day
If I/we fail to pick up my/our child/children by the appointed time, I/we understand that a late fee of ___________ per quarter hour (or portion thereof) will begin to accrue after the above stated pickup time.
If I/we fail, without notice, to pick up my/our child/children at the above stated time, or arrange for someone else to pick them up, the provider will make 3 attempts to contact me/us. If the provider is unable to contact me/us, the provider should contact the emergency person listed on the Application/Record of Child Information sheet, or person on the contingency list, to advise them my/our child/children are still in their care without notice from me/us. If, for any reason, there is no telephone service the provider will contact police to request assistance in contacting me/us or my/our emergency persons.
Provider agrees to keep my/our child/children for 1 hour after the above stated pick-up time, with late fees accruing, before contacting the local police and/or the Child Abuse Hotline if contact cannot be made with parents/guardians or emergency persons.
Provider will continue normal responsibilities for the child's protection and well being and agrees not to discuss your tardiness in arriving with your child/children beyond reassuring them you or someone known to them will be there soon to pick them up.
Parents/Guardians agree to advise provider immediately of any changes regarding their personal contact information, including addresses and phone numbers for home and work and cell phone numbers. Parents/Guardians also agree to provide immediate notice to the provider of any changes for their emergency contact or contingency persons.
______________________________________ ______________________________________
Parent/Guardian Provider A
______________________________________ ______________________________________
Patent/Guardian Provider B
______________________________________ ______________________________________
Date signed Date signed
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