Fillable ALTERNATE ARRIVAL / RELEASE AGREEMENT CHILD CARE CENTERS

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ALTERNATE ARRIVAL / RELEASE AGREEMENT CHILD CARE CENTERS

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DEPARTMENT OF CHILDREN AND FAMILIES http://dcf.wisconsin.gov
Division of Early Care and Education
DCF-F-CFS0104-E (R. 06/2021)
ALTERNATE ARRIVAL / RELEASE AGREEMENT – CHILD CARE CENTERS
Use of form: This form is voluntary. However, this completed form, when on file in the child's record, meets the requirements
of DCF 250.04(6)(a)3. and DCF 251.04(6)(a)5. and 251.095(4)(a)2. And may be used by certified operators to outline the plan
for a child to come or go from the center if the child is not accompanied by a parent or other authorized person. Personal
information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wisconsin Statutes].
Instructions: Complete this form for placement in the child's file when the child will arrive at the center from school,
home or other activities, or depart from the center to go to school, home or other activities, and the child will not be
accompanied by a parent or other previously authorized person or transported by the center. This form should be updated
as information changes. Periodic review with the parent / guardian is recommended to ensure safety. If the center
transports the child, the department’s form “Transportation Permission – Child Care
Centers” may be used to obtain
parental authorization.
ARRIVAL INSTRUCTIONS
My child
(Child’s name)
will arrive at
(Name of center)
from
(School, home or other activity)
by way of
(Walking, bicycle, bus, car pool, etc. Be as specific as possible.)
at
A.M. OR P.M.
(Time of arrival)
on
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
(Days of the week)
My child will arrive from this destination with OR without center supervision.
RELEASE INSTRUCTIONS
My child
(Child’s name)
will leave
(Name of center)
by way of
(Walking, bicycle, bus, car pool, etc. Be as specific as possible.)
to go to
(School, home or other activity)
at
A.M. OR P.M.
(Time of departure)
on
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
(Days of the week)
My child will travel to this destination with OR without center supervision.
ADDITIONAL INSTRUCTIONS
I understand that I am responsible for notifying the center of any changes in this schedule such as vacation, school
conference days, etc.
SIGNATURE – Parent
Date Signed (mm/dd/yyyy)
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ALTERNATE ARRIVAL RELEASE AGREEMENT CHILD CARE CENTERS

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Completed 22 July 2021

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