Indiana Child Care Provider Forms
Licensed Centers
- Application for Child Care Center Variance or Waiver
- Application for Construction Permit for Child Care Facility - State Form 49454
- Attestation Statement - State Form 48629/BCC 0012
- Breast Milk Procedure 49954
- Cleaning Schedule 49959
- Consent to Release Information for Licensed Centers, Licensed Homes, Unlicensed Registered Ministries, and CCDF LLEPs - State Form 53323 (R2/3-10) / BCC 0330
- Food Serving Sizes 49956
- Health Care Program for Child Care Centers: Child Care Center Health Record - State Form 49969
- Health Care Program for Child Care Centers - Procedure for Skin Care - Diapering - State Form 49971
- Healthcare Program for Childcare Centers - State Form 45877/BCC 0054
- History of Immunizations - State Form 49445/BCC 0036
- Injury Report Form for Licensed Child Care Centers
- Licensed Child Care Center / Home Consent - State Form 50548(R2/7-06)/BCC 0080
- Manual Utensil and Equipment Washing 49958
- Menu for Infants (8-12 Months) 49951
- Menu for Toddlers 49952
- Menu Pattern 49957
- Menu Planner - Child Care Center 49955
- Monthly Report of Licensed Child Care Centers and Homes (As Required
by IC 12.17.2-2-1.5) - State Form 46789 (R/10-09)/BCC 0007 - Provider Response Form - State Form 53320 (7-07) BCC 0312
- Record of Medication Order 49968
- Request for Limited Adult Criminal History Information - State Form 8053
- Review / Assessment for Child Care Centers 46153 (R3/7-07)BCC 0320
- Safe Transportation of Food Responsibility Agreement
- Sample Intake Agreement Form
- Sample Menu for Infants (8-12 Months) 49950
- Sample New Employee Orientation Form
- Sanitation / Sterilization Procedures for Bottles, Nipples, Collars, Caps 49953
- Sanitizing Solutions 49973
- Supplement to Health Program Form - Infant/Toddler 45878/BCC 0055
- Supplemental Health Care Program for Child Care Centers - Providing Infant-Toddler Care-Handwashing Procedure 49961
- Supplemental Health Care Program for Child Care Centers - Providing Infant-Toddler Care-Suggested Feeding Plan 49963
- Supplemental Health Care Program for Child Care Centers - Providing Infant-Toddler Care-Weekly Record of Daily Needs 49960
- Taxpayer Identification Number Request (W-9) 23743
- Training Record Log
- Verification and Documentation of Universal Precautions Training Form
- Written Nutrition Food Service Program for Child Care Centers 46684/BCC 0051
- Written Nutrition Food Service Program Infant/Toddler Child Care Centers 46682/BCC 0053
Licensed Homes
- Application for Child Care Home Variance or Waiver 48269 (R/6-07)/BCC 0025
- Attestation Statement 48629/BCC 0012
- Breast milk Procedure 49954 (R/12-06)/BCC 0067
- Child Care Home Injury Report (Medical Attention Needed) State Form 54265 (5-10) / BCC 0221
- Child Care Home Licensing Report - State Form 46739 (R2/3-05)/ BCD 0011
- Consent to Release Information for Licensed Centers, Licensed Homes, Unlicensed Registered Ministries, and CCDF LLEPs - State Form 53323 (R2/3-10) / BCC 0330
- History of Immunizations 49445/BCC 0036
- Licensed Child Care Center / Home Consent - State Form 50548(R2/7-06)/BCC 0080
- Monthly Report of Licensed Child Care Centers and Homes (As Required by IC 12-17.2-2-1.5) - State Form 46789 (R/10-09)/BCC 0007
- PTQ Voluntary Decline Form
- Provider Response Form - State Form 53320 (7-07) BCC 0312
- Sanitizing Solutions 49973/BCC 0024
- Taxpayer Identification Number Request (W-9) 23743
- Verification and Documentation of Universal Precautions Training Form
Registered Ministries
- Application for Voluntary Certification Program (VCP) Variance/Waiver
- Attestation Statement 48629/BCC 0012
- Breast milk Procedure 49954 (R/12-06)/BCC 0067
- Checklist For Registered Child Care Ministries Sanitation Survey 49441 (R5/9-07)/BCC 0032
- Child Care Development Fund (CCDF) Provider Eligibility Standards (PES) Checklist, State Form 51363/BCC 0091
- Consent to Release Information for Licensed Centers, Licensed Homes, Unlicensed Registered Ministries, and CCDF LLEPs - State Form 53323 (R2/3-10) / BCC 0330
- History of Immunizations 49445/BCC 0036
- PTQ Voluntary Decline Form
- Parent's Notice 49444/BCD 0035
- Provider Response Form - State Form 53320 (7-07) BCC 0312
- Request for Limited Adult Criminal History Information -State Form 8053
- Safe Transportation of Food Responsibility Agreement
- Sanitation/Sterilization Procedures for Bottles, Nipples, Collars, Caps 49953 (R2/12-06)/BCC 0066
- Sanitizing Solutions 49973
- Taxpayer Identification Number Request (W-9) 23743
- Verification and Documentation of Universal Precautions Training Form
- Voluntary Certificate Program Checklist 49443
LLEP's (Legally Licensed-Exempt Providers)
- Child Care Development Fund (CCDF) Provider Eligibility Standards (PES) Checklist, State Form 51363/BCC 0091
- Consent to Release Information for Licensed Centers, Licensed Homes, Unlicensed Registered Ministries, and CCDF LLEPs - State Form 53323 (R2/3-10) / BCC 0330
Staff Only
You must be an FSSA staff member and be logged into the forms application to use these forms. To login, click on "Forms.IN.gov" on the right navigation under Online Services and then click on "State Employee Login". Fill in the blanks and click "OK".
FSSA SpotLight
Related Topics
- Become a Licensed or Registered Child Care Provider
- Become a Certified Unlicensed CCDF Provider
- Download Child Care Facility Listings
- Economic Dimensions of the Childcare Industry in Indiana Study
- IACCRR
- Child Care Advisory
- Reasons why the Indiana Poison Center has stopped offering Mr. Yuck stickers
- Communicable Disease Guideline Chart for Child Care Centers
- Childhood Immunization Schedule
- Childhood Immunization Schedule – Parent Friendly Version
- Childhood Immunization Schedule – Spanish Version
- Children and Hoosiers Immunization and Registry Program
- Public Playground Safety Handbook
- Sharpening Your Knowledge about Lawn Mower Injuries
