Get Form 5226 R 1989-2024

FEES WILL BE PAID IN THE FOLLOWING MANNER POLICIES CDS Personnel CHILD MEDICATION WILL BE ADMINISTERED ONLY UPON MY WRITTEN REQUEST UNDER THE FOLLOWING CDS CONDITIONS LAUNDERING CHILD S/CHILDREN S SOILED CLOTHING WILL/WILL NOT BE DONE ON A ROUTINE BASIS. I WILL PROVIDE THE FOLLOWING TO MEET CDS PROGRAM REQUIREMENTS I ACKNOWLEDGE A SHARED RESPONSIBILITY WITH CDS FOR CHILD ABUSE PREVENTION SIGNATURE OF SPONSOR DATE SIGNATURE OF CDS REPRESENTATIVE OR FCC PROVIDER REVERSE OF DA FORM 5226-R JUL 89. DISCLOSURE Disclosure of requested information is voluntary however if information is not provided individuals may not be able to participate in CDS programs. NAME OF SPONSOR Last first MI PROGRAM VALID FROM Month day year to month day year SERVICE Check appropriate box FULL DAY PART DAY SCHOOL AGE PART DAY PRESCHOOL FCC HOME HOURLY AGE GROUP CATEGORY Check appropriate box INFANT TODDLER PRESCHOOL AGE I agree to enroll my child/children in the CDS Facility/Family Child Care Home located at PROGRAM SERVICES PROGRAM OPERATING HOURS ARE AS FOLLOWS List hours CDS personnel MON THURS SUN TO TUES FRI WED SAT SERVICES FOR MY CHILD/CHILDREN WILL BE AS FOLLOWS List hours Sponsor SERVICES WILL NOT BE AVAILABLE ON List time/date CDS personnel I WILL BE NOTIFIED IN ADVANCE WHENEVER POSSIBLE OF ADDITIONAL PERIODS OF NON-SERVICE AS DETERMINED BY CDS PERSONNEL. CHILD MAY BE DENIED CARE WHEN ILLNESS PRECLUDES PARTICIPATION IN ROUTINE PROGRAM ACTIVITIES PRIOR NOTICE REQUIREMENT List amount of time required to terminate services CDS Personnel UNIQUE CONSIDERATIONS Sponsor I REQUEST THE FOLLOWING SPECIAL NEEDS OF MY CHILD/CHILDREN AS ACCOMMODATED MY CHILD/CHILDREN REQUIRES THE FOLLOWING SPECIAL ITEMS WHICH I WILL SUPPLY NON APPLICABLE FOR HOURLY SERVICES DA FORM 5226-R JUL 89 EDITION OF AUG 83 IS OBSOLETE USAPPC V3. NAME OF SPONSOR Last first MI PROGRAM VALID FROM Month day year to month day year SERVICE Check appropriate box FULL DAY PART DAY SCHOOL AGE PART DAY PRESCHOOL FCC HOME HOURLY AGE GROUP CATEGORY Check appropriate box INFANT TODDLER PRESCHOOL AGE I agree to enroll my child/children in the CDS Facility/Family Child Care Home located at PROGRAM SERVICES PROGRAM OPERATING HOURS ARE AS FOLLOWS List hours CDS personnel MON THURS SUN TO TUES FRI WED SAT SERVICES FOR MY CHILD/CHILDREN WILL BE AS FOLLOWS List hours Sponsor SERVICES WILL NOT BE AVAILABLE ON List time/date CDS personnel I WILL BE NOTIFIED IN ADVANCE WHENEVER POSSIBLE OF ADDITIONAL PERIODS OF NON-SERVICE AS DETERMINED BY CDS PERSONNEL. CHILD MAY BE DENIED CARE WHEN ILLNESS PRECLUDES PARTICIPATION IN ROUTINE PROGRAM ACTIVITIES PRIOR NOTICE REQUIREMENT List amount of time required to terminate services CDS Personnel UNIQUE CONSIDERATIONS Sponsor I REQUEST THE FOLLOWING SPECIAL NEEDS OF MY CHILD/CHILDREN AS ACCOMMODATED MY CHILD/CHILDREN REQUIRES THE FOLLOWING SPECIAL ITEMS WHICH I WILL SUPPLY NON APPLICABLE FOR HOURLY SERVICES DA FORM 5226-R JUL 89 EDITION OF AUG 83 IS OBSOLETE USAPPC V3. 00 FEES AND CHARGES CDS Personnel RATES FOR PROGRAM SERVICES ARE AS FOLLOWS MISCELLANEOUS FEES FOR PROGRAM SERVICES ARE AS FOLLOWS AN OVERTIME/LATE FEE OF per WILL BE CHARGED STARTING AT HOURS. PAYMENT OBLIGATION IS BASED ON HOURS I AGREE TO USE SERVICES NOT ON ACTUAL HOURS OF CHILD ATTENDANCE UNLESS THEY EXCEED THE HOURS CONTRACTED. IN THE EVENT OF ABSENCE OF MY CHILD/CHILDREN FROM CARE DUE TO ILLNESS FEES WILL/WILL NOT BE REDUCED. .