Business Forms for Family Child Care Providers

Many of the links below go to PDF files. You must have Adobe Acrobat Reader on your computer to read them. Download a FREE copy now.

Child Care Database

Use this pdf-icon-small form to request changes to the information about your family child care business that is posted on the Office for Children's website. Child care center staff should use this separate pdf-icon-small form.

Sample Child Care Agreement Form

This form (pdf-icon-small English, NEW - pdf-icon-small Spanish) outlines policies and procedures that parents must agree to when enrolling children in a family child care program. You can modify this agreement to fit your own business.

Sick Child Care Policy

Sick children who attend child care programs while they are contagious can make others sick. The Sick Child Care Policy form (pdf-icon-small English, NEW - pdf-icon-small Spanish) helps parents understand the expectation that they should not bring children to child care when sick and that they should remove sick children from care as soon as possible.

Administering Prescription or Nonprescription Medication Record

By law, you must complete medication administration training in order to legally give medication to children in your care. You can use this pdf-icon-small form to document medication parents have authorized you to give their children. You can create your own form, but you must keep a record of any medication you administer. 

Child File Form

This form (pdf-icon-small English, NEW - pdf-icon-small Spanish) helps you gather and organize important information needed for each child in your care.

NEW - Business and Visit Checklist

Being organized is the key to success at the required home visits with your specialist. Use a pdf-icon-small checklist form  like this or create your own to help you gather and organize important information needed for your Permit Renewal visit or the USDA Child and Adult Care Food Program visits.

Emergency Contacts Information Form

This is a form (pdf-icon-small English, NEW - pdf-icon-small Spanish) parents fill out so that you will know how to reach them during an emergency. It also lists the people they have authorized to pick up their children from your program.

Emergency Response Plan Template

You are required to have a written emergency plan that covers evacuation plans, emergency preparedness plans and parent notification plans. You can create your own form or use this form (English, NEW - pdf-icon-small  Spanish).

Injury or Accident Report

You can use this pdf-icon-small form to document injuries that occur to children while in care.

Checklist/Agreement to Use a Substitute Child Care Provider

You can have a substitute work in your business. The total hours of hours of substitute care is 240 hours. To make sure your substitute is ready to care for children you need to track that the sub has completed all the safety and health requirements and knows the important parts of your program. You can use this form (pdf-icon-small English, pdf-icon-small  Spanish) or create your own to help you make sure your substitute is prepared to care for children in your absence. You can use this form (pdf-icon-small English, pdf-icon-small Spanish) to make sure parents are notified and provide authorization for their children to receive care from a substitute.

Authorization for Emergency Medical Treatment Form

Parents fill out this form (pdf-icon-small English, pdf-icon-small Spanish) to authorize you to take their child to the hospital or urgent care facility if the parents cannot be reached in time. It also includes information that will be useful to the medical professionals treating the child.

Evacuation/Fire Drill Form 

Use this form (pdf-icon-small English, pdf-icon-small Spanish) to document monthly drills. You will be required to present it when you apply for your permit renewal.

Monthly Shelter-in-Place Drill Form 

If there is a community emergency, officials may tell residents to "shelter in place." Each month, practice moving the children quickly into the shelter-in-place. Use this form (pdf-icon-small English, pdf-icon-small Spanish) to record the results of your practice drills. The shelter-in-place in your home should have the food, equipment and supplies in this Emergency Preparedness and Supplies Guide.

Change of Adults Living in Your Home

If anyone age 18 or older moves into your home after you have received your child care permit, submit sections C, D and E of the Home Child Care Facility Application form pdf-icon-small English or pdf-icon-small Spanish to the Office for Children. You must also submit a Sworn Statement or Affirmation for Child Day Programs form pdf-icon-small English or pdf-icon-small Spanish and a Child Protective Services Central Registry Release of Information form. To request a copy of the CPS Release of Information Form in English or Spanish, please email Tammi Daniels or call 703-324-8100, TTY 711. Mail all three forms to: The Fairfax County Office for Children, Community Education and Provider Services, 12011 Government Center Pkwy., Suite 800, Fairfax, VA 22035.

USDA Food Program

Family child care providers who participate in the USDA Child and Adult Care Food Program must post one of these flyers (pdf-icon-small English) (pdf-icon-small Spanish) and posters (pdf-icon-small English) (pdf-icon-small Spanish) to notify parents that the provider particpates in the program.


Contact Fairfax County: Phone, Email or Twitter | Main Address: 12000 Government Center Parkway, Fairfax, VA 22035
Technical Questions: Web Administrator

ADA Accessibility | Website Accessibility
Awards | FOIA | Mobile | Using this Site | Web Disclaimer & Privacy Policy | Get Adobe Reader
Official site of the County of Fairfax, Virginia, © Copyright 2015

Website Feedback Website Feedback    Globe with various flags representing Web site language translations   Language Translations

Return to Graphic Version