Provider Forms

General Forms (No ECE Number)

• Authorization for Protective Services Record Checks
• 2018 Informal-Relative Checklist.pdf
• Disaster Planning Form – Center & Facility
• Disaster Planning Form – Home, Informal, Relative
• Disaster Planning Form – Home, Informal, Relative & In-Home
• Child Care Provider Medical Report
• Request to Amend Application – 2022
• Tiered Reimbursement

ECE Numbered Forms

• ECE-CC-0162B Change of Information Notification
• ECE-CC-1 Application for Child Care Services
• ECE-CC-3 Child Health Assessment
• ECE-CC-3B Statement of Good Health
• ECE-CC-7 Provider Information Form
• ECE-CC-8A PS Check
• ECE-CC-8B Statement of Criminal Record
• ECE-CC-10A Request for Payment Child Care Services
• ECE-CC-10G Child Care Attendance Sheet
• ECE-CC-10K Child Care and Responsible Pet Ownership
• ECE-CC-10J Pet Acknowledgement Form
• ECE-CC-10E Emergency Info Form
• ECE-CC-14 Letter of Intent and Needs Assessment
• ECE-CC-14 Letter of Intent and Needs Assessment (Final)
• ECE-CC-14A Facility Info Packet
• ECE-CC-15 Facility Application
• ECE-CC-23 Fire Escape Plan
• ECE-CC-25 Medication Permission Slips
• ECE-CC-26 Child Care Provider Incident Report Form
• ECE-CC-30 Periodicity Chart