Sample Forms

Sample Parent Evaluation Form

What do you like best about how our program provided care for your child? 

What do you wish we would do differently about caring for your child? 

What else can you suggest that would help us to do a better job? 

What actions might you take that would help improve the care of your child when he/she is with our program? 

Would you recommend our program to other parents? Why or why not? 

Other comments:

Sample Parent Transporting Children Policy

In operating my child care business my first responsibility is to protect the health and safety of the children in my care. When parents drop off and pick up their children, I want to make sure their children are transported safely. When a parent transports children under the influence of alcohol or drugs or fails to use an appropriate car seat, it creates an unsafe transportation situation for the children. If, in my opinion, a child cannot be safely transported to or from my home, I will ask the parent not to transport the child and will propose the alternatives listed below. (If the parent refuses to agree to one of the alternatives and insists on transporting the child, I will immediately call the police and report the unsafe driving situation.)

1)   I will call someone to pick up the child from the following list of people who are authorized to do so:  

____________________      ____________________________
                  Name                                Phone number

____________________      ____________________________
                  Name                               Phone number

____________________      ____________________________
                  Name                               Phone number

2)   I will call a cab to pick up the child and the parent. The parent will pay the cab fare.

3)   If the parent has failed to bring an appropriate car seat for the child, I will ask the parent to drive home 
      without the child and return with an appropriate car seat installed in the car.

      I ___ will / ___ will not charge a late pickup fee under these circumstances.

 4)   Other acceptable alternatives proposed by the parent:   _____________________________________


Privacy/Confidentiality Policy (Also link with Contracts/Policies)

It is the policy of my program to protect the privacy of the families in my care. I will do so by following these procedures:

  1. I will abide by our state's privacy law. I will only share information with our state's child care licensing department that I am required to share.
  2. I will keep all records and information about your child and your family private and confidential, unless I have your written permission to reveal specific information.

The following situations are exceptions to this general rule:

I will occasionally post photographs of your children around my home and in photo albums that may be seen by prospective clients to my program. Your child's name may appear on artwork, cubbies, or on other objects around my home. I will use an electronic monitor to listen in on a sleeping baby. If I see members of your family in a public setting (park, school, church, shopping mall, etc.), I will feel free to initiate contact that acknowledges our business relationship.

I ask that you also respect the privacy of my family by not sharing any information you learn about my family with others, without my written permission.

















Sample Contract Termination Language

“This contract may be terminated by the parent/guardian by giving two weeks written notice in advance of the ending date. Payment by parent/guardian is due for the notice period, whether or not the child is brought to the provider for care.

The provider may terminate the contract at will.

Failure by the provider to enforce one or more terms of the contract does not waive the right of the provider to enforce any other terms of the contract.”


Sample Termination Notice

This note is to let you know that I will not be able to offer my child care services to

                              (child’s name)                                                         (Date)
__________________________________  effective ___________________ .

I will continue to provide my regular child care services until this date. According to our written contract, you are required to pay for my services up until this date, whether or not your child is present. 

_________________________________________    __________________ 
                         Provider Signature                                                        Date

_________________________________________    __________________ 
                          Parent Signature                                                          Date   


Sample Demand Letter

May 2, 20xx

Lucy Stone

1234 Collier Ave

St. Paul, MN 55103

Dear Lucy:

I provided child care services for your daughter, Mary, from January 1, 20xx to April 1, 20xx at a fee of $150 per week. On April 1, 20xx you informed me that you would not be bringing Mary back any more. At that time you owed me for $150 for the week of March 28 - April 1st.

You did not give me a two week written notice, which our contract requires. You therefore owe me $300 for this two-week notice period (April 4 - April 15).

I am requesting that you pay me $300 by May 13, 20xx. If I do not hear from you by then, I will have no choice but to take legal action against you, at which time I will sue you for $300, plus all court costs.


Paula Provider