Family child care licensing documentation

• Allergy Form - if applicable (PDF)

• Contract & Policy Guidelines (PDF)

• Family and Group Child Care Rule Summary (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)

• Child Information Sheet (PDF)

• Immunization Record Requirement Tracking Form (PDF)

• Permission to Administer (PDF)

• Activity & Transportation Authorization Form (PDF)

• Pool Guidelines (PDF) Please review this document prior to using a pool or wading pool

• Swimming Pool Permission Form (PDF)

• Swimming Pool Risk Factors for Parents (PDF)

• Wading Pool Best Practices for Providers (PDF)

• Wading Pool Permission Form (PDF)

• Wading Pool Risk Factors for Parents (PDF)

Infant-specific

• Infant Rolling Over Statement (PDF)

• Parent Consent for Swaddling (PDF)

• Physician Directive for Infant Sleep Position (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 DHS form (PDF)

• Weekly Attendance Schedule DHS form (PDF)

• Variance Request Notice for Parents DHS form (PDF)

Once the documents are completed, please return them to:
Sourcewell - Child Care Licensing
PO Box 219
Staples, MN 56479

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

• Age Distribution (PDF)

• Background Study Log (PDF)

• CCAP monthly attendance template (PDF)

• CCAP daily attendance template (PDF)

• Checklist for Provider's Records (PDF)

• Checklist for Children's Records (PDF)

• Contract & Policy Guidelines (PDF)

• Diapering Area Disinfectants Statement (PDF)

• Emergency Contacts Template (PDF)

• Emergency Preparedness Plan (PDF)

• 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 (PDF)

• Substitute Tracking Form (PDF)

• Water Testing Labs (PDF)

• Non-Traditional Hours Policy & Guidelines (PDF)

• Variance Procedure (PDF)