Licensing Forms

Have you been in need of a state required licensing form for an enrollment and did not have an extra copy?

Many County Licensing Units post links to these forms on their respective County websites. Check on your county's web site.   Link to list of county licensing agencies.

Link to Rule II

Link to Statute 245A (training requirements)

Forms from DHS  Department of Human Services

Forms which are required are available on the DHS website under 'General Forms'.  Any other documentation can be recorded on any formatted form of your choice.  Check yours or other county pages for examples of what can be utilized."

The highlighted forms are state required for each child's file.

 

  1. Family Child Care Admission and Arrangements (9-18)

  2. Family Child Care Allergy Information Form (7-17)

  3. Family Child Care Liability Insurance Notice to Parents/Guardians 8-18)

  4. Child Care Immunization Form (PDF)  (12/13)

  5. Child Care Immunization Form (PDF) (4-19)  Not required until 2020

  6. Mandated Reporter Policy (6-18)

Additional Forms on the DHS Web Site:

 Documentation family child care license holders must maintain.

Alcohol and Drug Abuse Policy (6-18)

Certificate of Compliance MN Workers' Compensation Law  (11-16) 

Child Care Emergency Plan (10-17)   

Keeping Kids Safe (planning guide for child care emergency plan) (10/17)

Emergency Phone Numbers (6-18)

Floor and Escape Plan (3-08)

Grievance Procedure -Sample (6-18)

Monthly Crib Safety Inspection Form  for Family Child Care Providers/Annual Certification of Crib (6-14)

Storm and Fire Drill Log (6-18)

The licensed program must also have documentation of the following: Attendance records if enrolled in the CACFP, Pet rabies documentation, completed background studies, compliance with training requirements, records of employees, substitutes or helpers, license holder policies. Link to a pdf document.

 

Other DHS Forms and Documents.

  1. Age Group Definitions (6-18)

  2. DHS Emergency Preparedness     Link to Form Template.

  3. Emergency Preparedness:  Links to resources    Background information

  4. Do I Need a Background Study? (2018)

  5. Electronic Licensing  Inspection Checklist Tool (ELICI) (DHS 2018) 

  6. Family Child Care Monitoring Checklist (DHS 2018)

  7. 2018 New Licensing Requirements and Technical Assistance Checklist (1-18)

  8. Fix-It Ticket Form (1-2-2018)

  9. Infant Rolling over Parent Statement for Infant Less Than Six Months Old (6-18)

  10. Prescription and Non-Prescription Medication Administration Permission (6-18)

  11. Physicians Directive for Infant Sleep Position (6-18)

  12. Poisonous Plants in Family Child Care (6-18)

  13. Rule and Statute Summary (9-18)

  14. Safe Sleep Standards and Training Requirements (2-18)

  15. Serious Injury Reporting Form (9-18)

  16. Swaddling Consent for an Infant (6-18)

  17. SUID and AHT Off-Year Training Video Verification (2-18)

  18. Swimming Pool Risks (6-18)

  19. Swimming Pool Permission Form (6-18)

  20. Travel and Activity Authorization (9-18)

  21. U.S. Consumer Product Safety Recalls Website

  22. Wading Pool Permission Form (6-18)

  23. Wading Pool Risks (6-18)

  24. Wading Pool Best Practices (6-18)

  25. New NET Background Study Information 

See Your Respective County for 

  1. Background Study (PDF)   (Sample from Scott County)

  2. Child Roster (PDF)  (Sample from Scott County)

  3. General Travel and Activity Authorization (PDF)

  4. Injury Incident Report Form (PDF)  (Sample from Scott County)

  5. Monthly Fire and Storm Drill Log  (Sample from Scott County) with time space to record 

  6. Parent Survey Email Permission (PDF)  (Sample from Scott County)

  7. Permission to Administer (PDF)  (Sample from Scott County)

  8. Provider Policy (PDF)  (Sample from Scott County)

  9. Scott County Videotape Book Training Questionnaire (PDF)   (Sample from Scott County)

  10. Training Record (PDF)  (Sample from Scott County)

  11. Well Water (PDF)  (Sample from Scott County)

  12. Yard Hazard Plan (PDF)  (Sample from Scott County)

PROVIDER QUESTIONS - Links to DHS

Link to get DHS Updates sent to your email.

Helpful Documents

Definition and Requirements for Co-applicants, Adult Caregivers, Substitutes and Helpers  (Sample Dakota County)

Keeping Kids Safe (Instructions for filling out the Emergency Preparedness Form pp.25-26)

​Fix It Ticket Implementation Legislative Report Document (12-22-2017) Family Child Care Violations Eligible for a Fix-It Ticket as of January 1, 2018   on page 10. 

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Minnesota Child Care Provider Information Network

MCCPIN

P.O. Box 1136

                                                                                                                   Prior Lake, MN 55372                   651-636-1989