Miss Shannon's Family Child Care

Where we play to learn!


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Enrollment Forms

Privacy Policy

I will do all I can to protect your family’s privacy and I will abide by Iowa’s privacy law.  I will keep all records and information confidential, unless I have your written permission to share parts of it.


I ask for the same respect for my family’s privacy as well.

Parent Signature ________________________Date _________

Parent Signature ________________________ Date _________

Provider Signature_______________________ Date _________


Agreement to Policies


It is my desire to have my child(ren) enrolled in the child care home of Shannon Uglum and Miss Shannon’s Family Child Care. 

Please initial each item to indicate that you understand and agree to abide by each policy.

____ ____ I understand that we must provide completed medical and dental forms.

____ ____ I understand that Shannon must have an up-to-date immunization record and health history for each child on file. I also understand that the record needs to be updated at least once a year, and each time my/our child(ren) get immunizations.

____ ____ I understand that payments are due on Friday for the following week of care. Late fees are $10 per day.  (payment is due whether or not the child attends)

____ ____ I have contracted for the hours of _________ to _________.

                        For (   ) Year round care, (   ) summer care, (   ) school year only.

                        For the following days of the week:

(   ) Monday, (   ) Tuesday, (   ) Wednesday, (   ) Thursday, (   ) Friday

____ ____ I understand the overtime policy. ($4.00 per hour for prearranged; $15 for each 15-minute-period that’s not prearranged)

____ ____ I understand the illness policy (Page 5).

____ ____ I understand that I will be responsible for finding back-up care for when Shannon is unable to provide care (Page 4).

____ ____ I understand the pick-up policy for anyone other than parents (Page 18).

____ ____ I understand the vacation policy (Page3).

____ ____ I understand the supply fee policy (Page 5).

____ ____ I understand the returned check policy (Page 5).

____ ____ I understand the termination policy by both parties (Page 16).

____ ____ I understand the house rules, and will help to enforce them (Page 7).

____ ____ I agree to give a minimum of 2 weeks notice of my intent to withdraw my child from the child care home.  And I understand payment will be due whether or not the child attends.


By signing below, you are agreeing to a legally binding document.


I have read, understand and agree to abide by the policies contained on this form as well as those contained in the Parent Handbook. I further understand that failure to abide by these policies could result in immediate termination of child care services.


Mother ________________________ Date ____________________


Father _________________________ Date ____________________


Provider _______________________ Date ____________________


Financial Agreement


The following agreement is made between parent(s) and provider for child care services for __________________________________.

Parent/guardian name: _______________________________ Cell: _______________

Parent/guardian name: _______________________________ Cell: _______________

Home Phone: _______________ Address: __________________________________________

Provider’s name: Shannon Uglum    Phone: 309-0575      Cell: 314-2279

e-mail: missshannons_littlepeople@yahoo.com  Address: southwest side of Des Moines

Starting date: _____________________

Expected Hours:

Fees:  Standard care:

Full time -- maximum of 50 hours per week $                   per week (5 unpaid vacation days)

Part time -- maximum of 10 hours per day    $                   per day (not eligible for vacation days)

Standard care rates are payable on Fridays by pick-up time each week, for the following week of care. Please remember your check and do not put me in a position to ask for it.

Overtime rates: $15.00 for each  15 minute period past contracted time. Payable at next drop off, or a $10 per day late fee will be charged.

Drop-in care: $30 per day. Due at drop off time or a $10 day late fee will be charged.

Prearranged overtime: $4 per hour. Payable at next drop off time or a $10 day late fee will be charged.

Holding fee: $50 per week to secure a position for up to one month, with Miss Shannon’s Family Child Care for the child named above. The holding fee is non-refundable, and does not apply towards weekly fee. The position will be considered open until the holding fee is received.

Trial Period:  A 2-week trial period will be in effect starting the first day of care and ending on ___________.  During this trial period either party may choose to discontinue services without written notice.  Parents will only be charged for the days care was actually given during the trial period.

Termination of Agreement:  Either parents/guardians or provider may terminate the child care agreement by giving 2 week written notice. Payment for child care services is due for the 2 week notice period, whether or not the child attends. The provider can terminate the contract immediately without giving notice if parents/guardians do not make payments when they are due.


______Parent Initials ______Parent Initials ______ Provider Initials


Child Intake Form


Child’s full name __________________Preferred nickname _____________

Date of Birth __________________

Address __________________________________________________

Food Allergies _____________________________________________

Health Allergies _____________________________________________


Mother/Guardian’s Full Name ________________________________

Place of Employment _______________________________________

Address of Employment_______________________________________

Work phone ____________________Cell Phone _________________

Home phone ____________________

Mother’s Birthday ______month _______day


Father/Guardian’s Full Name __________________________________

Place of Employment ________________________________________

Address of Employment______________________________________

Work phone ____________________Cell Phone _________________

Home phone ____________________

Father’s Birthday ______month _______day


To be contacted if parents/guardian cannot be reached in an emergency

Emergency contact____________________ Relationship to child _________________

Daytime phone _______________________ Cell phone ________________________

Emergency contact____________________ Relationship to child _________________

Daytime phone _______________________ Cell phone ________________________


Child’s Siblings

Name __________________ Age __________ Birthday _____________

Name __________________ Age __________ Birthday _____________

Name __________________ Age __________ Birthday _____________


Child’s Physician _____________________Phone __________________

Address __________________________________________________

Child’s Dentist _______________________Phone __________________

Address __________________________________________________


Former Babysitters/ Childcare providers, Phone Numbers, reason for leaving:

OK to contact? _________________


Does your child have any special fears or needs? ________________

If yes, Please Explain  ________________________________________________

Any medical or emotional disorders/developmental (slow or advanced) diagnosed or suspected? ___________________________________________________________

Are there any areas you would like your child to work on? ______________________________________________________________

Are there any restrictions on playing or activities? ______________________________________________________________

How do you handle discipline at home?_________________________________ ______________________________________________________________


What is your child’s usual bedtime? ___________Waking time? ________

Naptimes? __________How long are they? ___________

Does your child have a special blanket or toy for nap? ________________


Is your child potty trained? _________

(If in process please let me know your procedure so we can keep your child moving forward with this next step in their development.) ____________________________________________________________

What words do you and your child use for potty training? ____________________________________________________________

How does your child behave when sick? ______________________________________________________________

How does your child feel about child care?  And being dropped off by Mommy or Daddy? ______________________________________________________________


Please list a typical daily schedule for your child










What are your expectations of a family child care home?





Pick-up Permission Form


I hereby give my permission for my child(ren) to leave Miss Shannon’s Family Child Care with the person(s) named below.  I understand that it is my responsibility to notify Shannon, in writing, of any changes. I also understand that I need to notify Shannon if any of the persons below will be picking the child on a specific day. When they arrive to pick up the child(ren), Shannon will ask for a photo ID for the protection of the child. This form must be signed and on file in advance; telephone permission will not be accepted.





Parent ____________________________date ____________


Parent ____________________________date ____________

Provider __________________________ date ____________




I hereby grant permission for my child, ____________________ to use all of the playground equipment and participate in all of the activities at Miss Shannon’s Family Child Care.

With the following restrictions: ___________________________________

I understand that ride-on toys, slide, climbers, chairs, wading pools, sprinklers, sandboxes and other toys are used on a regular basis.


I will not hold the caregiver responsible for injuries incurred while on the equipment at the child care home, providing the children are supervised and the equipment is in good repair.




Parent’s Signature _____________________________Date ____________________


Parent’s Signature _____________________________Date ____________________


Permission to Photograph


I, ___________________ (parent/guardian) give permission to Shannon Uglum to photograph my child ___________________ (child’s name) for the following purposes:

-Display in personal scrapbook            Grant Permission? Yes or No
-on website (no names will be used)     Grant Permission? Yes or No
-display in child care home                  Grant Permission? Yes or No

I understand it is my responsibility to update this form in the event I no longer wish to authorize one or more of the above uses.  I agree that this form will remain in effect during the entire time my child attends Miss Shannon’s Family Child Care.

Parent Signature ______________________________ Date _________

Parent Signature ______________________________ Date _________

Provider Signature _____________________________ Date _________



Permission to Transport


I give permission for my child(ren) ________________, to leave the child care home with Shannon Uglum. This permission form is for, but not limited to, walks around the block, driving kids to and from school and preschool, and occasional field trips. When children are transported, it will be in the provider’s van only. 


The following safety precautions will be followed during transportation: All passengers are individually secured with a safety belt, harness, or safety seat recommended for the child’s age and weight.  Children are never seated in the front seat.  A list of emergency numbers for each child will be present in the vehicle. An emergency first aid kit is always present. I also understand that Shannon will carry her cell phone anytime they leave the house in case of emergency or I need to reach her for any reason.


If permission is not granted to transport the child(ren), other arrangements must be made by the parent/guardian for any day that Shannon must transport the other children.


I understand and agree to the above guidelines and expectations for transportation of my child.


Parent/Guardian’s Signature ______________________ Date __________


Parent/Guardian’s Signature ______________________ Date __________


Provider Signature _____________________________ Date __________



Permission for emergency care in parental absence.


Child’s Full Name ___________________________ Birth date _____________

I, _______________________ parent or guardian of the child named above, give my permission to Shannon Uglum , child care provider, to secure and authorize such emergency care and treatment as my child might require while under the Provider’s supervision.  I also authorize the Provider to administer emergency care or treatment as required, until emergency medical assistance arrives. I also agree to pay all costs and fees for any emergency medical care and treatment for my child as secured or authorized under this consent.

NOTE: Every effort will be made to notify parents immediately in case of emergency. The following information is required if I am unable to contact one of them and the injury requires immediate attention.

Name of Parent or Legal Guardian: __________________ S.S. # ____________

Address _____________________________________________

Home Phone ___________ Work ______________ Cell ___________

Name of Parent or Legal Guardian: __________________ S.S. # __________

Address _______________________________________________

Home Phone _____________ Work ____________ Cell ____________

Doctor: _______________________________

Address: ______________________________________________________

Phone: _______________________

Dentist ______________________________

Address: _______________________________________________

Phone: ________________________

Preferred Hospital to Contact: _______________________________

Address: _____________________________________________

Phone: _____________________

Person(s) to be contacted in emergency if parents are unavailable:

Name ______________________ Relationship __________________

Home Phone ________________ Work Phone ___________________

Name _____________________ Relationship __________________

Home Phone ________________ Work Phone ___________________

Current medications: _______________________________________

Known allergies: __________________________________________

Date of last tetanus: _________________________

Insurance company and policy number: _____________________________________


Parent/Guardian Signature: ____________________________ Date: _____________


Parent/Guardian Signature: ____________________________ Date: _____________