Forms for Child Care Providers

Below are links to various forms required for use with The Child Development Division.  We use Adobe Acrobat PDF files as a means to electronically provide forms. You will need to have Adobe Reader software installed to access them (available FREE from Adobe's Website).  Simply click on the title of the form you wish to view/download.


Record Check/Background Clearance Forms

Record Check Authorization Form
A record check form must be submitted for all individuals employed by the program and/or who are regularly present. This is the same form to be used by Family Child Care Homes for individuals who live and/or will be living in the Family Child Care Home and who are 16 years of age or older.

Record Check Authorization Form - Multi-Site Programs
Programs, use this form if you have multiple locations and with staff that work in multiple locations.  A record check form must be submitted for all child care program staff.

Family Child Care Home (FCCH) Census List
This form is used by registered and licensed Family Child Care Homes to notify CDD when children under the age of 16 years are residing in the home.


Forms For All Providers

Direct Deposit Authorization Form
To receive/cancel  and/or change payments from the Department for Children and Families, Child Development Division directly deposited into your bank account, you must submit this authorization form.

Professional Development Verification Cover Sheet
To verify and submit Professional Development into Bright Futures Information System (BFIS) Quality and Credential Account.

Provider Rate Agreement, Part 1 Financial Services
To receive payments from the Department for Children and Families, Child Development Division you must submit this form.

Provider Referral Agreement
Use this form to send information about your program/services to the child care referral specialist. This information will be shared with parents and others on the Bright Futures Information System (BFIS).

W-9 Form
To receive payments from the Department for Children and Families, Child Development Division, you must submit this request for Taxpayer Identification Number and Certification.


SAMPLE Forms For All Providers

Aquatic Plan (Sample)
This sample aquatic plan meets licensing regulation requirements for Center Based Child Care and Preschool Programs and Afterschool Programs.  Family Child Care Homes may also use this sample aquatic plan. 

Care Plan for Child with Special Needs (Sample)
This is a sample form that can be used to document the plan for inclusion of a child with special health care needs and disabilities in the program.

Child Admission/Registration Form (Sample)
This sample form may be used to collect enrollment information children.

Child Care Attendance Sheet (sample)
This sample form may be used to record when children come in and leave, on a daily basis.

Child Care General Health Examination Form
This form can be used for child care programs and required documentation of a child’s general health examine. Other physical forms used by the health provider’s office documenting the child’s age appropriate well care exam and information regarding any health conditions and medications that may impact the care of the child in child care are also acceptable.

Child's File Checklist (Sample)
This form can be used for child care programs as a resource to ensure required documentation is included in a child's file in the program.

Child Incident Report (Sample)
This sample form may be used to record any for any accident, injury or medical emergency that leaves a visible mark or first aid has been administered, even when medical treatment is not required.

Emergency Response Guide for Child Care Programs
This is a booklet that outlines the basics of emergency response plans for child care programs. It also includes sample forms for plans. Click here to download a Word version of the forms.

Evacuation Drill Record (Sample)
This sample form may be used to record evacuations completed by the child care program.

Field Trip Permission Form (Sample)
This sample form may be used to get parent/guardian permission to take children on field trips.

First Aid Supply Checklist (Sample)
This is a sample checklist child care programs can use to evaluate their first aid supplies, and document when they are checked.

General Permission Statements (Sample)
This sample form may be used to get parent/guardian permission for emergency medical care, wading pool and swimming activities, transportation, walking trips, and information about religious activities.

Medication Permission Form (Sample)
This sample form may be used to get parent/guardian permission to administer medication.

Medication Administration Log (Sample)
This sample form may be used to maintain a record of medications administered to children in care.

Non-Prescription Medication Permission Form (Sample)
This sample form may be used to get parent/guardian permission to administer non-prescription medications, lotions and ointments.

Pesticide Record (Sample)
This sample form may be used to maintain a record of all pesticide use/administration in the child care program.

Referral Consent Form (Sample)
This sample form may be used to get a parent's consent prior to making a referral for the child to community resources.

Transportation Log (Sample)
This sample form may be used to make a record of when the child care program provides transportation to the children in the program.

Staff/Volunteer Forms

Acknowledgement of Mandatory Reporting Responsibility (Sample)
This sample form can be used to maintain a record of staff acknowledgement of their mandatory reporting responsibility.

Staff File Affidavit (Sample)
This is a sample form that can be used by school based programs when utilizing Center Based Rule 8.2.1 or Afterschool Programs utilizing ASP Rule 5.23.

Staff File Checklist (Sample)
This is a sample checklist to use by all programs to ensure required documentation is in the staff file.

Staffing Plan (Sample)
This sample form can be used to maintain a record of the staffing of the program.

Partner, Auxiliary Staff, or Volunteer Information Form (Sample)
This sample form can be used to collect necessary contact information on Partner Staff and Volunteers as required by regulation.

Volunteer Sign In & Out Sheet (Sample)
This sample form can be used to record when volunteers are present in your child care program.

Due Date Checklists

Center Based Child Care and Preschool Programs Due Date Checklist
This is a document with the due dates required by the Vermont Child Care Licensing Regulations for Center Based Child Care and Preschool Programs.

Family Child Care Home Due Date Checklist
This is a document with the due dates required by the Vermont Child Care Licensing Regulations for Registered and Licensed Family Child Care Homes.

Page was last revised 7/24/2017


 

Child Development Division

Deputy Commissioner Reeva Murphy
DCF - Child Development Division
280 State Drive
Waterbury, VT 05671-1040
Phone: (802) 241-3110 or 1-800-649-2642
Fax: (802) 241-0846

http://dcf.vermont.gov/cdd

Twitter    YouTube