Social Services
Day Care - Forms for Providers
Many of the following resources are made available in PDF format. 
Required Forms, one for each family:
- Child Care Reporting Notification - Reporting suspected child abuse or neglect
- Insurance Statement - Notification to parents that provider does not carry liability insurance on their day care business
- Provider Policies: - sample provider policies to be discussed with parents (you must write your own). Sample 1: Karley's Family Day Care Sample 2: Rinky-Dinky Daycare
- Your Child's Safety in Licensed Family Child Care - Rules of family and group day care given to parents
Required Forms for every Child:
- Family Day Care Admission and Arrangements - Information sheet on family and child
- Child Care Immunization Record - Record your child's immunizations or exemptions on this form for your child care provider.
- Absent Parent Permit for Emergency Medical/Surgical Care - Gives provider authorization to obtain medical care for the child
- Permission to Administer - To be signed by parent for provider to use non-prescription items
Forms that may be required:
- Permission to Administer Medication - Permission slip to be signed by parent allowing provider to administer prescription medication
- Smoking Sign - Must be posted near the daycare entrance if anyone in your household smokes in the house or attached garage during non-business hours.
- Alternate Infant Sleep Position Directive
- Swimming Pool Consent Form / Regulations - Permission by parent for a provider to use a swimming pool
- Wading Pool Consent Form / Regulations - Permission by parent for a provider to use a wading pool
Non-required but recommended forms:
- Family Day Care Supplemental Form - Non-required form for parents to use when describing their child to the provider
- Trampoline Consent Form - Permission slip to be signed by parent for a provider to use a trampoline
Logs and Checklists:
- Family Day Care Floor and Escape Plan
- Family Day Care Training Record
- Monthly Fire and Storm Drill Log
- Update and Summary of Children in Daycare
- Monthly Crib Safety Inspection Form
Forms Providers Need to Sign and Return to Sherburne County:
- Notification of Background Study - To obtain a background check on provider, any other person living in the household, and alternative care providers
Variance Requests:
- Variance Procedure
- Request for Variance in Age Distribution/Capacity - MN Rule 9502.0367: For provider to use when asking to be over capacity
Laws, Rules & Sherburne County Policies:
Social Services Contact:
Sherburne County Govt Center
ATTN: Social Services
13880 Business Center Dr NW
Elk River, MN 55330-1692
Office Location & Hours
hhs@co.sherburne.mn.us
Sherburne County Govt Center
ATTN: Social Services
13880 Business Center Dr NW
Elk River, MN 55330-1692
Office Location & Hours
| Phone: | 763-765-4000 800-433-5239 |
| Fax: | 763-765-4096 |
hhs@co.sherburne.mn.us
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