Licensing Forms

Licensing forms are available as printable PDF documents below. They must be completed manually.

Begin opening a form by clicking on its name or number. Next print the form and then fill in the required responses. Then mail the document to the appropriate Office of Child Care Regional Licensing Office.

If you have any questions about the use of a form, please contact your Regional Licensing Office.

Please note that the following indicators are used to define what type of child care facility each form represents:

(HOME/LFCCH) - family child care homes (small) and large family child care homes
(HOME) - family child care homes (small) only
(LFCCH) - large family child care homes only
(CTR/LOC) - child care centers and letter of compliance facilities
(CTR) - child care centers only
(LOC) - letter of compliance facilities only
(ALL) - centers, homes (small and large), and letter of compliance facilities

Checklists

Please print the desired "checklist" to use as a guide to select the appropriate forms required.

Initial Application - Child Care Center

Initial Application - Family Home

Initial Application - Large Family

Continuing Application - Child Care Center

Continuing Application - Family Home

Continuing Application - Large Family

Application for Resumption of Services

Application of Nonpublic Nursery Schools

Forms

[CJIS] 365 Day Request form

[DHMH 896] Immunization Certificate (ALL)

[DHMH 4620] Blood Lead Testing Certificate (ALL)

[100] Record of Professional Development Coursework (ALL)

[101] Record of Pre-Service Training for Family Child Care: Prior to becoming registered, Family Child Care providers are required to complete a minimum of 4 clock hours of approved training in each of the 6 Core of Knowledge areas in addition to other mandated training. The Core of Knowledge areas are: Child Development (Child Dev), Curriculum (Curr), Heath, Safety and Nutrition (HSN), Special Needs (Spe N), Professionalism (Prof), and Community (Comm).

[200] Application to Operate An Educational Program – Nonpublic Nursery School

[201] Nonpublic Nursery School Personnel Record

[300] Reportable Child Incident Form

[349] Application to Resume Service (Family): This form is used to apply for a family day care registration:  At a new address, if the last effective date of the registration at the previous address was not more than 6 months ago; or After a break in service of not more than 6 months, from the last effective date of the previous registration.

[672] Child Care Center Request for Continuing License or LOC

[673] Request for Continuing Family Child Care Home Registration

[675] Request for Continuing Large Family Child Care Home Registration

[1200] Child Care Center Application for License (LOC): This form may be used to apply for a Child Care Center License or a Letter of Compliance

[1201] Worker’s Compensation Insurance Information (LFCCH / CTR / LOC)

[1203] Personnel List and Staff Change Report (LFCCH / CTR / LOC)

[1203] Personnel List and Staff Change Report - (Fill-in Version ) (LFCCH / CTR / LOC)

[1204] Medical Report for Child Care (ALL)

[1205] Personnel Information (LFCCH / CTR)

[1206] Staffing Pattern (LFCCH / CTR / LOC)

[1209] Change in Facilities (LFCCH / CTR / LOC): Child Care Center regulations (COMAR 13A.16.03.07) and Letter of Compliance regulations (COMAR 13A.17.03.07) require that any changes in operation be approved by the Office of Child care (OCC). Examples include capacity, hours of operation, rooms used for care, and ages of children served. Obtain written approval from OCC before making the proposed change.

[1213] Variance Request (ALL)

[1214] Emergency Form (ALL)

[1215] Health Inventory (ALL)

[1216] Medication Administration Authorization (ALL)

[1216A] Seizure Medication Administration Authorization (ALL)

[1216B] Medication Incident Reporting Form

[1218] Menu Plans (LFCCH / CTR / LOC)

[1229] Substitute Form (HOME / LFCCH)

[1230] Family Child Care Home Application

[1240] Large Family Child Care Home Application

[1260] Release of Information (ALL)

[1261] Emergency Escape Plan (HOME)

[1267] Provider Information and Plan of Operation (HOME)

[1268] Environmental Health Survey (ALL)

[1270] Notice of Intent to Operate (CTR / LOC)

[1275] Additional Adult Application (HOME)

[1281] Request for Hearing (ALL)

[1285] Health History – Drop In (CTR)

[1295] Family Child Care Home Self-Assessment Guide (HOME)

Accident/Injury Record (ALL)

Allergy Action Plan

Asthma Action Plan

Daily Attendance Record (ALL)

Disaster Drill Record (ALL)

Facility and Other Emergency Numbers (ALL)

Fire Drill Record (ALL)

Infant Toddler Daily Food Intake and Activities (ALL)

Infant Toddler Checklist (HOME)

On-Call Agreement (LFCCH / CTR / LOC)

Permission Slip - Offsite Activities (ALL)

Permission Slip - Swimming/Wading Activities (ALL)

Staff Orientation Verification (LFCCH / CTR / LOC)

Substitute/Additional Adult/Volunteer Orientation Verification:  This is the former substitute orientation verification form revised to include use by additional adults and volunteers – (revised 11/7/16) (HOME)

Voluntary Surrender of a Family Child Care Registration (HOME)