Family child care licensing documentation

• Allergy Form - if applicable (PDF)
• Contract and Policy Guidelines (PDF)
• Rule and Statute Summary for Parents (PDF)
• Family Child Care Admission & Arrangements Form (PDF)
• Immunization Record (PDF)
• Liability Insurance Notification to Parents/Guardians (PDF)
• Mandated Reporter Policy/Abuse Notification Form (PDF)
• Permission to Administer (PDF)

• Checklist for Children's Records (PDF)

Required for all enrolled children:

• Admissions and Arrangements (PDF)
• Child Information Sheet (PDF)
• Immunization Form (PDF)
• Permission to Administer Medications (PDF)
• Travel and Activity Authorization (PDF)
• Liability Insurance Notice to Parents or Guardians (PDF)
• Mandated Reporting Policy (PDF)
• Rule and Statute Summary (PDF)
• Immunization Tracking Form (PDF)
• Contract and Policies Guide (PDF)

Infant-specific

• Swaddling Consent for an Infant (PDF)
• Infant Rolling Over Statement for Infant Less Than 6 Months Old (PDF)
• Physician Directive for Alternative Infant Sleep Position (PDF)
• Helmet Approval for Sleeping Infant (PDF)

Additional child forms, if applicable:

• Allergy Form (PDF)
• Wading Pool Risks (PDF)
• Wading Pool Permission Form (PDF)
• Swimming Pool Risks (PDF)
• Swimming Pool Permission Form (PDF)

Variance forms
To apply for a variance, please review Variance Procedure (PDF). If you are in compliance, please complete the following forms:

• Variance Request DCYF form (PDF)
• Weekly Attendance Schedule DCYF form (PDF)
• Variance Request Notice for Parents DCYF form (PDF)

Once the documents are completed, please return them to:
Sourcewell - Child Care Licensing
Staples, MN 56479

For all other variance requests, please contact your regional licensing specialist for more details on how to apply.

• Age Distribution (PDF)
• Annual Reporting Caregiver Information and Sub Use Form (PDF)
• Background Study Log (PDF)
• CCAP monthly attendance template (PDF)
• CCAP daily attendance template (PDF)
• Checklist for Provider's Requirements (PDF)
• Checklist for Children's Records (PDF)
• Contract & Policy Guidelines (PDF)
• Diapering Area Disinfectants Statement (PDF)
• Emergency Contacts Template (PDF)
• Emergency Preparedness Plan (DOC)
• Emergency Preparedness Plan Log (PDF)
• Employee Tracking Log (PDF)
• Fire Extinguisher Reservicing Options (PDF)
• Floor & Escape Plan Template (PDF)
• License Holder Training Log (PDF)
• Licensed Space Form (PDF)
• Monthly Fire & Storm Drill Log (PDF)
• Monthly Crib Inspection Log (PDF)
• Serious Injury Form (DOC)
• Substitute, Second Adult Caregiver, Helper Initial, and Ongoing Tracking (PDF)
• Substitute Tracking Form (PDF)
• Water Labs (PDF)

• Non-Traditional Hours Policy & Guidelines (PDF)
• Variance Procedure (PDF)