Forms For Child Care Providers

BACKGROUND/RECORD CHECK CLEARANCE FORMS
To sign the record check forms electronically, please download the form and save to your computer.
Record Check Authorization Form (pdf)
Record Check Authorization Form - Multi-Site Child Care Programs (pdf)
Family Child Care Home Census List (pdf)

FORMS FOR ALL PROVIDERS
IRS W-9 Form
Professional Development Verification Cover Sheet
Provider Profile Form
Provider Referral Agreement

SAMPLE FORMS FOR ALL PROVIDERS
If you would like a Microsoft Word version of any of these forms, please email AHS.DCFCDDInfo@vermont.gov.
Acknowledgement of Mandatory Reporting Responsibility (PDF)
Aquatic Plan (PDF)
Auxiliary Staff Information Form (Sample)
Care Plan for Child with Special Needs (Sample)
Center Based Child Care and Preschool Program Due Date Checklist
Child Admission/Registration Form (Sample)
Child Care Attendance Sheet Sample (PDF)
Child Care General Health Examination Form
Child's File Checklist (Sample)
Child Incident Report (Sample)
Emergency Response Guide for Child Care Programs Word version of the forms.
Evacuation Drill Record (Sample)
Family Child Care Home Due Date Checklist
Field Trip Permission Form (Sample)
First Aid Supply Checklist (Sample)
General Permission Statements (Sample)
Governing Body Form (Sample)
Health and Safety Monitoring Checklist, Afterschool Child Care Programs
Health and Safety Monitoring Checklist, Center Based Child Care and Preschool Programs
Health and Safety Monitoring Checklist, Family Child Care Homes
Medication Administration Log (Sample)
Medication Permission Form (Sample)
Non-Prescription Medication Permission Form (Sample)
Pesticide Record (Sample)
Referral Consent Form (Sample)
Staff Background Clearance Checklist (Sample)
Staff File Affidavit (Sample)
Staff File Checklist (Sample)
Staffing Plan (Sample)
Transportation Log (Sample)
Vermont Child Care Regulations Required Orientation Template
Volunteer Information Form (Sample)
Volunteer Sign In & Out Sheet (Sample)

Flood Resources

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