Forms

Forms for Providers

•  Opens a New Window. Background Study Documentation (PDF) Opens a New Window. : This form is required for a provider to document when a background study is initiated and when it is completed.
•  Opens a New Window. Chemical Usage Policy (PDF) Opens a New Window. : Required policy for all family child care programs and signed by all caregivers / employees.
• Department of Human Services (DHS) Licensing Application: Application for a Family Child Care License and Special Family Child Care License
•  Opens a New Window. Enrollment Form (PDF) Opens a New Window. : Use to submit enrollment to licensing.
•  Opens a New Window. Incident Report Form (PDF) Opens a New Window. : For documentation of any injury that occurs in the child care home.
• Monthly Crib Safety Inspection Form: Used to document monthly and annual verification that cribs are safe.
• Monthly Fire / Storm Drill Log (PDF) Opens a New Window. : For documentation of required monthly fire / storm drills.
• Parental Acknowledgement that Infant is Rolling Over Opens a New Window. : Signed statement from parent when an infant under the age of 6 months is regularly rolling over after being placed to sleep on his/her back.
• Parental Consent for Swaddling an Infant: This form is required if a parent wants the provider to use a swaddle such as a sleep sack. Swaddle is defined on the form.
• Physician Directive for Alternative Infant Sleep Position: Required if a parent wants their infant child to sleep in a position other than on their back to sleep.
• Variance Request Form (PDF): Used to request a variance to age distributions and/or capacity.
• Emergency Preparedness Plan: DHS template for required Emergency Plan Opens a New Window.  PDF Downl

Forms for Parents

• Admission and Arrangements Opens a New Window. : Parental permission to enroll child in providers child care.
• Allergy Information Form: Parents complete one form for each child with a known allergy.
• Immunization Record Opens a New Window.  PDF Download : Used to keep a current list of child’s immunizations.
• Mandated Reporter Notification Opens a New Window. : Policies and procedures provided to parents at time of enrollment regarding child abuse and neglect reporting.
• Permission to Administer Prescription Medication Opens a New Window. : Parental permission allowing provider to administer prescription medications.
• Permission to Administer Opens a New Window. : Parental permission to administer over-the-counter medication / products (1 form per child).
• Permission to Leave Premises Opens a New Window. : Parental permission for child to leave providers’ premises.
• Wading Pool Permission Opens a New Window. : Families to complete 1 form per child to allow them to use the provider’s wading pool.
• Wading Pool Risks :  This form must be given to parents with the Wading Pool Permission Form
• Rule Summary for Parents Opens a New Window. : A summary of Rule 9502 (Rule 2) to be given to parents at enrollment
• Family Child Care Liability Insurance Notice to Parents / Guardians: Opens a New Window.  Used to notify families enrolled in the family child care that the provider has insurance, when the policy is renewed or lapsed, any change in status of the insurance, and the annual notification of no insurance