Shenanigans Home Daycare Story
Shenanigans Home Daycare
142 Pommogussett Road
Rutland, MA
Hours of operation 7:30 AM- 4:00 PM
Daycare Handbook/Policies
​Dear Parent,As a licensed Family Child Care Educator, I would like to congratulate you on choosing licensedFamily Child Care. You have made an important child care decision for you and your family. TheDepartment of Early Education and Care (EEC) and I invite you to join in a partnership with usto ensure a high quality child care environment. This parent handbook and enrollment packetoutlines many of my policies and procedures that relate to the care of your child, as well asthe information I am required to give to you when you enroll your child in my care. Thishandbook will also acquaint you with some of the key EEC standards designed to ensure asafe, healthy and educational child care experience.I encourage you to maintain an open dialogue with me, as communication between parents andEducators are the foundation for a solid working relationship, and a good child care experience.Before filling out your child care enrollment form, please read through the information containedin this parent handbook.
My Childcare PhilosophyMy goal is to make sure that all parents have peace of mind that your child is being properly cared for while you are at work or away. I will take care of your child and show them that they are very important and loved. Your child's day will be filled with many fun activities that will stimulate him/her not only socially, but intellectually, emotionally, and physically as well. Through play, your child will learn the importance of cooperation and sharing. They will also learn social behavior and how to get along with others. They will learn how to understand their feelings, gain self confidence, respect for others and themselves. All these things that will stay with them for a lifetime!​A Word from EECEEC is the agency that oversees the early education and care and after school services forfamilies in Massachusetts. As the agency that licenses child care, EEC has quality standardsfor all licensed programs to ensure high educational value, as well as health and safety. Havinga license means that I have demonstrated that I meet the standards outlined in the EECregulations.To obtain your own copy of EEC Family Child Care Regulations, you may download them fromthe EEC website at:http://www.mass.gov/Eeoe/docs/EEC/regs_policies/20090122_606_cmr.pdfFor information about my regulatory compliance history, you may contact our local EEC regionaloffice, whose contact information is as follows:Central MA Office324-R Clark St, Worcester, MA 01606
Enrollment/CapacityMy current licensed capacity is 8, which is posted on my license. At any one time, I canonly care for the number of children that I’ve been licensed for, which may include my ownchildren, depending on their ages. In addition, EEC regulations state that I cannot care for morethan three (3) children under the age of two (2) without an assistant, with one of those childrenbeing at least 15 months old and walking unassisted. If you have concerns or questions about the number of children in my care, please feel free to discuss them with me.
Use of AssistantsI may have an assistant to help care for the child care children, provided they are approved byEEC. If and when I use an assistant, I will let you know ahead of time, and you will have anopportunity to meet the assistant that will be working in the program. I may also use volunteersfrom time to time, and although they will not be directly responsible for the care of children in theprogram, they will be on the premises and assisting me.NOTE: I am not currently utilizing a full time assistant. In the case of running out for doctor appointments and such I will use my back-up care which is only allowed to be in charge of the children 25 Hours a year. I will let you know the night before if I will be stepping out and will be using back up care.
Payment Policy /AttendancePayment is based on your child's spot and can be paid through Brightwheel. This App helps to keep track of your receipts and print out end of year summaries for taxes. Weekly payment is due regardless of attendance and is due on Thursday for the following week of care. If Payment is not received a late fee of $5 will be added per day until payment is received. I will be unable to watch your child(ren) until payment is received, no exceptions. I have the right to terminate your contract as well. Payment is based on contracted spots, not attendance. I will review fees annually, and parents will receive at least two weeks notice, in writing of any payment adjustments. ​Rate includes Breakfast, PM snack and Beverages.NOTE: Payment is always due in advance with no deduction for any absences, holidays, or closures due to providers policies, inclement weather, power outages, or other situations beyond our control.Late Pickup PolicyIf your child is picked up after their scheduled pick up time there will be an inconvenience fee of $25.00 per child, and is to be paid before/or with the following week's payment. I am very understanding of emergencies, therefore I am lenient at times. However,frequent late pickups will result in dismissal from my daycare. If you need care beyond the contracted hours you will need to prearrange this with the provider. The provider is under no obligation to provide an extension of time if such extension conflicts with the provider’s own plan. Late arrival does not justify late departure. Please be courteous and arrive on time. After hours is time with my family.
Paid Holidays/Days offNew years eveNew Years DayMemorial DayPatriots Day
Veterans Day
Independence Day (July 4th)Thanksgiving DayDay After ThanksgivingPresidents Day
Good Friday
Christmas eveChristmas dayDay after Christmas
Martin Luther king Jr Day
Juneteenth
Columbus Day
Note: If a holiday falls on a Saturday, it will be observed the day before (Friday). If the holiday falls on a Sunday, it is observed the next day (Monday).Some holidays/Days off are negotiable for care based on my personal schedule..Note: Parents/Guardians are responsible for finding back-up care for their children during unpaid provider vacations, paid holidays, and paid sick/persona/training days resulting in the daycare closing.
Paid Sick/Personal/Training DaysAs strong as my immune system has become over the years, I unfortunately still get sick from time to time. Because of this I allow myself paid sick days. Additionally I allow myself 4 personal days and 5 training days per year. These are in addition to the listed paid holidays/days off above. I also use these days for my continuing education classes (CPR, Pediatric First Aid, etc) in order to keep my childcare license in good standing. Of course I will give you as much of an advance notice as possible. Note: Parents/Guardians are responsible for finding back-up care for their children during provider vacations, paid holidays, and paid sick/persona/training days resulting in the daycare closing.
Unanticipated closure
There are several possible reasons why there could be an unanticipated closure..
A significant weather event which may include but is not limited to a State of Emergency declared and or a Travel Ban. If I feel that the conditions will not be safe I will notify you the night before the weather or if I feel the weather is getting too bad I will notify you to arrange early pick up. If you feel you will not be able to safely transport your child here and/or pick them up on time, please keep them home.
Loss of power for an extended period of time,Loss of water.Loss of heat that reduces the temperature in the house below 65 degrees,An illness,Jury Duty,Death in the family, etc.
Both fire exits will be cleared of snow upon arrival but please take caution with the driveway and please understand that having children in my care, including infants I am unable to leave the house and keep up with the driveway and walkway. I have no control of when the plow will show up. Please note that this is all beyond my control and payment is still due, if a closing or absence is to take place.
Provider Vacations I allow myself three weeks of paid vacation a year. The dates of my vacation will be posted at least two weeks in advance (unless an emergency arises). Note: Parents/Guardians are responsible for finding back-up care for their children during unpaid provider vacations, paid holidays, and paid sick/personal/training days resulting in the daycare closing.
Child's Absences and/or VacationsIf your child will not be attending daycare due to illness or other, please let us know as soon as possible so the day's activities won't be held up waiting for your child to arrive. Also, I need to know how many children I need to prepare meals/crafts for. No discounts will be given for your child's absences due to illness or days off/vacations. If your child will not be attending daycare for whatever reason, you are still required to pay your weekly rate for that child's spot.
Termination Policy The first week will be a trial period, in which case either party may terminate the contract without notice. After the first week of enrollment, two weeks written notice from parent or provider is required to terminate the contract, with the exception of gross misconduct on part of the provider, parent, or child. This is grounds for immediate discontinuation of service. In cases of non-payment, legal action may be taken, and the parents will pay all legal fees incurred.
Signing in & OutI am required to have all parents/guardians sign in and out for pick-ups and drop offs each day. I will be utilizing brightwheel for sign in/out. This gives me a written record of the child's attendance, hours, and the person who brought/picked up the child each day.​Sick PolicyI can care for mildly ill children in my program, however there will be times when you will need tokeep your children out of the program due to illness. Example: If your child has a fever, diarrhea orvomiting, you should keep them out of care until those symptoms have resolved for 24 hours. If a child becomes ill during daycare hours the parents will be contacted to pick up their child. Parents need to pick up their children within one hour of being notified. If parents are not available, the emergency contact person will be notified.Note: Once the child is removed from daycare due to illness, they may not return to daycare until symptoms requiring removal are no longer present. The child must also be void of any contagious disease, unless accompanied by a doctor's note stating the illness in question is not contagious, and the child is otherwise feeling well enough to participate in our daily schedule.
Plan for Meeting Potential EmergenciesEEC regulations require that I have a plan for meeting potential emergencies that may occureither during child care hours or at any time if they may affect the operation of the program.In the event of an evacuation emergency, I will contact the local authorities to determinewhether or not to evacuate the program, or to remain sheltered at the program.The escape routes from each floor of the licensed child care space are as follows:Front door which brings us to the driveway and Sliding deck door located in the back of the house which we can go around the home and down the driveway or into the neighbors back yard.In the event that a child goes missing from the program, I will do the following: Immediately call 911 then call parents/GuardianShould the program need to be evacuated in the case of a fire, natural disaster, loss of power,heat or hot water, or any other emergency situation, we will meet at an alternate location. Thedesignated meeting place(s) outside of the program for emergencies are: Rutland Community hall 250 main st Rutland, MA 01543If the program needs to be evacuated, I will notify all parents, as well as the appropriateauthorities (fire, police, etc.) and EEC. My method of doing that is as follows (cell phone,neighbor’s phone, payphone, etc.): Cell phone, if need be a neighbor's phone.I will ensure that no child has been left at the program after an evacuation by: Doing a headcount of children to align with my daily attendance
Medical EmergenciesIn case of EMERGENCY, I will administer the necessary first aid. The Rutland Police Department or Paramedic Unit will be called and your child will be transported to the hospital designated on your Emergency Transportation Authorization form. YOU WILL BE NOTIFIED IMMEDIATELY. If an ambulance is called to transport your child, the cost of the ambulance will be your responsibility. I am prepared with emergency caregivers in cases of unplanned absences of short duration caused by unanticipated circumstances such as illness or accident. You will be notified when an emergency caregiver will be used. If an emergency caregiver can not be located, you may be requested to pick up your children. You are responsible for all costs involved in emergency medical treatment, including emergency transportation, if required. I, Amanda Zarella , or my family will not be held liable for any sickness/injury of either parent/guardian or child while on these premises, or while the child is in the company of the myself
Note: In case of a serious accident or sudden illness requiring immediate medical attention, the following procedures will be followed.o A phone call to 911 is made.o Child's parents (or emergency contacts) are called.o Child is separated from the other children and appropriately cared for.0 Parent, provider, or ambulance takes the child and health records to the doctor or hospital.
Children’s RecordsEEC regulations require me to maintain an individual written record for every child I have incare. These records include the information that parents complete at enrollment, as well asprogress reports, incident reports and other documentation regarding your child’s care.Records are updated at least annually, but may be updated as frequently as is needed.As a parent, you have access to the record that I maintain for your child, and you have the rightto add information or to request that information in your child’s record be changed or deleted.You also have a right to receive a copy of your child’s record; however I may charge areasonable fee for that copy.EEC regulations require that I make children’s records available to EEC at any time that EECmay request these records, such as during a licensing/monitoring visit, a complaintinvestigation, or a financial review of my program. Failure on my part to provide these recordsto EEC could result in EEC citing me for regulatory non-compliance or taking legal actionagainst my license. When EEC staff members review children’s records in order ensure that Iam in compliance with EEC regulations, at times they may copy and keep the information foundin these records in order to review my compliance with all EEC regulations and policiesapplicable to my program. This information will be kept in my EEC Licensing file or in EEC’sfinancial monitoring file if the information involves issues related to subsidized care. EEC isrequired by law to keep confidential any personally identifiable information found in children’srecords collected and maintained by EEC staff members. EEC has a Privacy Policy whichdiscusses how EEC keeps such information confidential. That policy can be found by going tothe EEC website at http://www.eec.state.ma.us/docs1/20101124_eec_privacy_policy.pdf.Please let me know about any questions you have regarding your child’s record.
Maintaining a Safe EnvironmentEEC has a number of licensing standards related to safety in a Family Child Care Home. Mostof these standards outline common safety precautions such as making dangerous materialsinaccessible to children, covering outlets, having a first aid kit, practicing evacuation drills,gating stairs, windows, or heating elements, posting emergency numbers, and maintaining aclean, hazard-free indoor space. Also, the outdoor space must be safe and hazard free andthere should be no access to a busy street, water, construction materials, rusty or broken playmaterials, debris, glass, or peeling paint.
FirearmsThere are currently legal firearms in my home. The firearms are not located in the daycare approved space. They are located in a locked safe inside of a locked room.
Lead Poisoning PreventionAll Family Child Care Educators are required by EEC to provide parents with informationregarding the risks of Lead Poisoning. The following are some facts that all parents shouldknow about lead and lead poisoning:• Lead poisoning is caused by swallowing or breathing lead. Lead is poison when it getsinto the body.• Lead can stay in the body for a long time. Young children absorb lead more easily thanadults. The harm done by lead may never go away. Lead in the body can:o Hurt the brain, kidneys, and nervous systemo Slow down growth and developmento Make it hard to learno Damage hearing and speecho Cause behavior problems• Most of the lead poisoning in Massachusetts comes from lead paint dust in older homes.Many homes built before 1978 have lead paint on the inside and outside of the building.• When old paint peels and cracks, it creates lead paint chips and lead dust. Lead dustalso comes from opening and closing old windows.• Lead dust lands on the floor. Lead gets into children’s bodies when they put their handsand toys in their mouths. Children can also breathe in lead dust. Children between theages of 9 months and 6 years are most at risk.• Important: Home repairs and renovations also create lead dust.• Most children who have lead poisoning do not look or act sick. A lead test is the onlyway to know if your child has lead poisoning. Ask your doctor to test your child for lead.Some children may have:o Upset stomacho Trouble eating or sleepingo Headacheo Trouble paying attentionAs mentioned earlier, if your child is over nine (9) months of age, you will need to providedocumentation to me that your child has been screened for lead poisoning. Most children willbe screened annually until either age three (3) or four (4), depending on where the child lives.I am required to disclose to you if I am aware of any known sources of lead in my home.Information regarding known sources of lead in my home is as follows: My home is lead free.For more information on lead poisoning, you can visit http://www.mass.gov/dph/clppp or call theChildhood Lead Poisoning Prevention Program at (800) 532-9571
Cleanliness I take the well-being of your child very seriously and work hard to provide an environment that is as healthy as possible. I am committed to keeping my home and the children in it as clean as possible, in order to help minimize and/or prevent the spread of germs. My home is kept clean and disinfected at all times. I thoroughly clean surfaces that children come in close contact with using soap and water, or Lysol, etc. The high chairs are cleaned between each use, and the diaper changing tables are cleaned and disinfected between each diaper change. Toys are cleaned and disinfected often, and water-play tables are cleaned and disinfected before being filled with water and carefully supervised when in use. Hand washing is the single most effective practice in preventing the spread of germs. I wash my hands many times throughout the day, as well as the children's hands before and/or after engaging in a thorough list of activities.
Diaper PolicyEach child has his or her own clearly labeled diaper bin, Diapers are checked frequently, and changed every two hours or more often if required. Diapers containing #2 are changed immediately. The changing table is cleaned and disinfected between each diaper change, and hand washing of the childcare provider and child is performed after each diaper change.
Toilet Training I am more than happy to encourage potty training as long as the child is ready. The initial start needs to be done at home for at least two weeks with success before it can be effectively started at daycare. Parents will be required to supply pull-ups. Children will be allowed to come to daycare in cotton training pants/underwear after they have been accident free for at least two weeks in pull-ups. Communication between parents and the daycare provider is imperative for a successful transition from diapers to toilet. SupervisionSupervision is critical to keeping children safe. I and any assistants in my program willappropriately supervise children in order to ensure their health and safety at all times. I will usegood judgment and consider several factors in determining the appropriate level of supervisionfor children including age, developmental needs, behavioral characteristics, the nature ofactivities and the space we are using, as well as the number of caregivers present at any giventime. If you have any questions about how I supervise the children in my program, feel free toask me.
Safe SleepSupervision of children is equally important during the times that a child is sleeping at theprogram, particularly when that child is an infant. EEC has very specific regulations around safesleep practices. All infants are placed on their backs to sleep, unless a child’s physician ordersotherwise (such an order must be given to me in writing). I check on children every 15 minutesduring nap time. If your child is less than six months old, I will directly supervise them duringnap time for the first six weeks they are in care. For more information regarding Safe Sleep,Please feel free to review the ‘Family Child Care Policies’ section of www.eec.state.ma.us.
Personal BelongingsNo toys should be brought from home. Little ones have a difficult time sharing with others, and it is even harder with their own special toys. Exceptions being for nap time, Show and Tell and other special activity days. I am not responsible for any loss or breakage of your child's personal items. All personal items must be clearly marked with the child's name.
Birthdays and HolidaysEach child's birthday is his/her "Special Day." I will buy the child a gift that is from all of us. If you feel you must purchase a personal gift for the birthday child, I ask that you give this outside of the childcare home. I will also provide a cake, cupcakes, or treats for your child's special day. I will let you know which day we will celebrate. I also have holiday parties occasionally throughout the year. Please let me know what holidays your child does and does not celebrate.
Meals/Snacks I provide a nutritious and well balanced breakfast and afternoon snack. Parents/guardians provide lunch, baby food/formula. I serve morning breakfast at 8:00am, lunch at 11:00am and afternoon snack at 3:00pm. You are responsible for feeding your child if he or she will arrive after the set mealtime. Milk or juice is served with all the meals and snacks, and water is offered throughout the day. The children are offered the food, but they will not be forced to eat. Children who choose not to eat will not be served additional food until the next meal time. Hands are washed before and after meals, and teeth are brushed after lunch. The snacks for each week constantly vary in order to ensure the children receive a well-balanced diet. It is my goal to offer nutritious snacks to the children in my care, as nutrition is a vital part of a child's health. Children need to eat well-balanced meals in order to meet his or her daily energy needs and to help them build a strong body and mind. We know that the good food habits a child develops will help them prevent cavities, iron deficiency anemia, and obesity, etc - all common nutritional problems in young children.
Food Allergies If your child has a food allergy, you must notify us in writing so that we can make appropriate substitutions. The written notification should list appropriate food substitutions and must be updated at least every 6 months.
Curriculum and Progress ReportsAll Family Child Care Educators must carry out a routine that is flexible and responds to theneeds and interests of children in care. The routine must include things such as; meeting thephysical needs of children in care, sixty minutes of physical activity every day, child-initiated and Educator-initiated activities and daily outdoor play, weather permitting. Additionally, theEducator must develop a curriculum that engages children in developmentally appropriateactivities by planning specific learning experiences. The curriculum must include things such as;learning self-help skills that foster independence, opportunities to gain problem solving anddecision making competencies and leadership skills and opportunities to learn about proper nutrition, good health and personal safety. I am also responsible for providing an environmentthat promotes cultural, social and individual diversity.In addition, progress reports must be completed periodically for all children in care. For infantsand children with identified special needs, I will be completing progress reports every threemonths. For toddlers and preschoolers, those reports are completed every six months, andschool age children will have a yearly progress report completed for them.I will be sharing your child’s progress reports with you, as well as offering an opportunity tomeet and discuss your child’s progress. Feel free to ask me about curriculum and progressreports and how they are implemented in my program.
Child GuidanceWhen it comes to interactions and the guiding of children’s behavior, the goal of all Educators is to maximize the growth and development of children, as well as keep them safe. My Child Guidance Policy is as follows: My philosophy is that you use discipline to teach a child. I achieve this through love, consistency, and firmness. I stress two main patterns of behavior: respect for other people and respect for property. The children are explained the rules of the child care home frequently, so they are all familiar with the guidelines. Please keep in mind that there WILL be disagreements between children. Young children, especially, who are not adept at communication, have a hard time expressing their feelings. Sometimes they hit or throw toys, etc. Although teaching children appropriate behavior is what I will be doing, remember that this behavior is normal in most cases.The following methods of discipline will be used:· Encourage children to solve problems themselves· Intervention and discussion· Redirection to another play area. Loss of privileges (Toy goes in time out)
NOTE: If I feel there is a chronic behavioral issue that needs attention, I will let you know so that you and I are handling it in the same way and your child has continuity in discipline between our homes. These types of behaviors might include such things as biting, use of bad words, chronic hitting, etc. Together, we will try to find a solution. You may be called to remove your child if his/her behavior prevents me from being able to properly care for the other children. If the problem continues, other arrangements for the care of the child will have to be made, for the safety and well being of all. Under NO CIRCUMSTANCES will there be any spanking, physical abuse, verbal abuse, name-calling or isolation used. Neither food nor sleep will ever be withheld from children as a means of punishment. As a home care provider, I have a responsibility by law to recognize and report any evidence of child abuse--physical or emotional-or neglect. This is strictly for the benefit of your child.
Medication AdministrationEEC has regulations requiring Educators to have a policy regarding the administration ofmedication to children in care. Although I am a nurse, EEC guidelines are to be followed. The following guidelines are common to all programsthat are licensed by EEC:
Prescription Medication• Prescription medication must be brought to the program in its original container andinclude the child's name, the name of the medication, the dosage, the number of timesper day and the number of days the medication is to be administered. This prescriptionlabel will be accepted as the written authorization of the physician.• The program will not administer any medication contrary to the directions on the labelunless authorized by written order of the child's physician.• The parent must fill out the Authorization for Medication Form before the medication canbe administered.
Non-prescription Medication• The program needs written parental authorization to administer oral non-prescriptionmedication. The parent must fill out the Authorization for Medication form, which allowsthe Educator to administer the non-prescription medication. The statement must berenewed on a weekly basis.• In the case of unanticipated non-prescription medication that is used to treat mildsymptoms (e.g., acetaminophen, ibuprofen), the program must still have written parentalauthorization, however it must be reviewed annually.• The Educator will make every attempt to contact the parent prior to the child receivingthe non-prescription medication unless the child needs medication urgently or whencontacting the parent will delay appropriate care unreasonably.
Topical Ointments and Sprays• Topical ointments and sprays such as petroleum jelly, sunscreen, diaper rash ointmentand insect repellant will be administered to the child with written parental permission.The signed statement from the parent will be valid for one year and include a list oftopical non-prescription medication.• When topical ointments and sprays are applied to wounds, rashes, or broken skin, theEducator will follow the written procedure for non-prescription medication which includesthe written order of the physician, which is valid for a year, and the Authorization forMedication form signed by the parent.
All Medications• The first dose must be administered by the parent at home in case of an allergicreaction.• All medications must be given to the Educator directly by the parent.• All medications will be stored out of the reach of children. All medications that areconsidered controlled substances must be locked and kept out of reach of children.• The Educator will be responsible for the administration of medication. In his/herIn absence, the designated person will be Robert Zarella.• The program will maintain a written record of the administration of any medication(excluding topical ointments and sprays applied to unbroken skin) which will include thechild's name, the time and date of each administration, the dose, and the name of theperson administering the medication. This completed record will become part of thechild's file.• All unused medication will be returned to the parent if possible, or disposed of inaccording to Department of Public Health guidelines.
Oral HealthProper oral health begins at home, and I will be reinforcing good oral health practices with yourchild each day. If your child is in care for more than 4 hours per day, or he/she will be receivingat least one meal while in care, I am required to assist your child with tooth brushing at theprogram.[x ] I would appreciate it if you would provide me with a toothbrush and toothpaste for yourchild, which I will store in a safe and sanitary manner at the program.
Parent NotificationsI am required by EEC regulations to notify you of certain information about my family child carehome. These notifications include, but are not limited to:• an injury to your child;• allegations of abuse or neglect regarding your child;• if another educator will be caring for your child;• the administering of first aid to your child;• whenever a communicable disease has been identified in the program;• children being taken off the child care premises;• the existence of firearms in my home;• if there are any changes in my household composition,• prior to any pets being introduced into the program;• whenever special problems or significant developments arise.
Mandated ReportingAs a licensed Educator in Massachusetts, I must operate my program in a way that protectschildren from abuse and neglect. As such, I am a mandated reporter (under M.G.L. c.119 s51A)and must make a report to the Department of Children and Families (DCF) whenever I havereasonable cause to believe a child in the program is suffering from a serious physical oremotional injury resulting from abuse inflicted upon the child, or from neglect, no matter wherethe abuse or neglect may have occurred or by whom it was inflicted.
Communication and Staying InvolvedIt is important to keep an open dialogue with me as your child’s Educator, and to maintain anactive role in your child’s care. Feel free to visit, not just at pick up and drop off time, but at avariety of times during your child’s day—it’s your right as a parent. Please also make sure tofollow-up with me if you have any questions about the program or your child’s care.I look forward to working with your family and providing a great experience for your child(ren)!
Daycare Handbook/Policies acknowledgment
Please initial each page of the handbook and sign and date this acknowledgment and return prior to enrollment. A copy will be given to you of the signed documents.This handbook/policies may be updated from time to time and notice will be provided as updates are implemented.
I have received,reviewed and agreed to the daycare handbook/ policies. It is my responsibility to familiarize myself with this and if I have any questions to ask for clarification.
Recipient signature/Date _________________________________________________________________________________
Provider signature/Date___________________________________________________________________________________