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.


Licensed Child Care Programs

Record Check Authorization Form - Licensed Programs
A record check form must be submitted for all licensed child care program staff.  Please include a Record Check Census Form.

Record Check Authorization Form - Multi-Site Licensed 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 licensed child care program staff.  Please include a Record Check Census Form.

Record Check Census Form - Licensed Programs
Please include a copy of this form along with the record check form.


Registered Child Care Providers

Record Check Authorization & Census Form - Registered Programs
A record check form must be submitted for all staff and household members in registered child care programs.


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).

Specialized Child Care Agreement
The Specialized Child Care Services Provider Agreement is for child care provided by registered, licensed or certified legally exempt child care providers to children with special needs.

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

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 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.

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.

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.

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

Partner 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.

Page was last revised 12/12/2016


 

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

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