Child Care & Development Program Provider Service Agreement Sample Contracts
Child Care & Development Program Provider Service AgreementChild Care & Development Program Provider Service Agreement • June 28th, 2024
FACILITY INFORMATION Facility Name: Facility ID: Physical Site Address: City: County: State: Zip: Telephone: Fax (if applicable): Mailing Address (if different than physical address): City: County: State: Zip: FACILITY DIRECTOR Instructions: The Child Care Director signing this agreement will be held accountable for compliance by the entire facility with the responsible conditions outlined in the provider service agreement. The individual listed here must be the person signing the Provider Service Agreement. Last Name: First Name: Title: E-mail: License Number: SSN or Tax ID Number: CHILD CARE RESOURCE & REFERRAL (CCR&R) AGENCY CCR&R Agency Name: CCR&R Representative Name: Phone and Email: Back-Up Representative Name: Phone and Email: