Fee Payment Agreement
Child's Name: Parent/Guardian's Name:
Address:
City/State/Zip:
Phone:
Name of person paying fee:
Agreed arrival time: Pick‑up time:
Days receiving care (Circle) M T W TH F
A fee of _______________ per __________ is due and payable on _______ of each ________________________.
I understand that closing time is 6:00 pm. I also understand that I will pay $1.00 per child, per minute, after my pre‑designated pickup time that my child/children remain/s in child care. I will pay this fee at the time I pick‑up my child/children.
I agree to give at least two weeks written notice of termination of this agreement, withdrawal from care, or change in hours, days or statistics in this agreement.
I agree to pay a fee of $30.00 for tuition paid after the due date.
I understand that I am responsible for the terms of payment as stipulated above.
Signature Relationship Date
Signature Relationship Date