Child’s Care Program
Third-Party Payment Consent Form

Child's Full Name
Date of Birth
Parent/Guardian Name

Third-Party Payer Information

Organization/Agency Name
Contact Person
Phone Number
Email Address
Billing Address

Consent

I authorize the above-named third-party (organization/agency) to pay directly for the care program services provided to my child listed above. I consent to the sharing of necessary enrollment, attendance, and billing information between the Child’s Care Program and the third-party payer.

I understand and agree to the above consent.
Parent/Guardian Signature
Date
Program Administrator Signature
Date