Department Resources

Forms for Family Child Care Providers

Below are forms you can use in the business of family child care in Fairfax County.

Fairfax County is committed to nondiscrimination in all county programs, services and activities. To request reasonable accommodations or to receive the information from the below forms in an alternate format, call 703-324-8100 or TTY 711.

You are strongly encouraged to call 703-324-8100 and register for one of our free Preparing for Your Permit orientations designed to help you understand the full process for applying for your family child care permit. You are also encouraged to read about the process and permit requirements on the web page, Become a Family Child Care Provider.

Home Child Care Facility Application Form English / Spanish
Sworn Statement or Affirmation for Child Care Programs Form English / Spanish

You must also submit 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 ncsceps@fairfaxcounty.gov or call 703-324-8100, TTY 711.

Waiver Agreement and Statement for the Fingerprint National Background Check English

Each adult 18 years or older living in the home including the applicant and all substitute care providers, must submit a signed waiver granting the Office for Children permission to request and review results from the Fingerprint National Background Check. We will not be able to send you this information until we have a waiver and fee for each adult in your home.

Once you submit the waiver and the $27 per adult, we will send you instructions on where to go to get the fingerprints done. An additional $8.72 fee is required for each adult at the time you schedule the fingerprinting appointment online. Please do not add this fee to the $27 payment.

Change of Adult Living in Your Home English / Spanish
If anyone age 18 years or older moves into your home, or your child turns 18 years of age after you have received your child care permit, submit sections C, D and E of the Home Child Care Facility Application form in English or Spanish to the Office for Children. Each adult must complete and submit the Sworn Statement form, the Child Protective Services Central Registry Release of Information form and the Waiver Agreement and Statement form. To request a copy of the CPS Release of Information Form in English or Spanish, please call 703-324-8100, TTY 711. Mail all three forms to: Fairfax County Neighborhood and Community Services, Community Education and Provider Services, 12011 Government Center Parkway, Suite 800, Fairfax, VA 22035.

Child Care Agreement English / Spanish
This form outlines the policies and procedures of your business and is an agreement of the care and payment for care between you and the parents. You can modify this form to fit your business practices.

Child Care Website Database - Provider Form
Use this form to request changes to the information about your family child care business or center program that is posted on the Early Childhood Programs and Service's website.

Child's File Checklist English / Spanish
This form helps you gather and organize important information needed for each child in your care.

Daily Attendance Record English / Spanish
This form captures the daily arrival and departure of children in your care.

Permission to Participate in Swimming and Wading Activities English / Spanish
This form documents a parent's permission for a child to participate in a swimming or wading activity and asks the parent to identify the child's swimming ability.

Permit Visit English / Spanish
This form is helpful in preparing for your renewal visit from your child care specialist. It lists the items you need plan and prepare ahead to take care of needed requirements, certifications and documents that you need to be able to show your child care specialist to successfully complete your renewal visit.

Playground and Outdoor Safety Checklist English / Spanish
This form helps you plan ahead to make sure the area and equipment that children will be using is safe and appropriate for their use. It helps you think through how to prepare for safe outdoor play, supervise children according to their age and how to contact local authorities if child is missing or severely injured.

Emergency Contact Information English / Spanish
This is a form 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 Preparedness and Supplies Guide English / Spanish
This checklist will help you create an emergency preparedness plan needs to cover as many ways as you can to protect children. Make sure your plan for a variety of emergencies-fire, severe weather, terrorism, intruders, health crisis, loss of utilities, environmental disasters and relocation or evacuation as well as the supplies needed to support your plan.

Emergency Preparedness Plan English / Spanish
You are required by law to have a written emergency plan the covers emergency evacuation, emergency preparedness plans including shelter-in-place and lockdown procedures, and a parent notification plan. Your plan includes ways to practice with all household members and document your preparedness.

Monthly Evacuation/Fire Drill Record English / Spanish
Use this form to document monthly drills. You will be required to present it when you apply for your permit renewal.

Monthly Shelter in Place and Lockdown Drill Record English / Spanish
If there is a community emergency, official may tell residents to shelter-in place. Use this form to document that you practice moving the children quickly in your designated shelter-in-place. You can also this form to document your lockdown drill which is required annually. A SIP is a place in your home where you keep food, equipment and supplies in case you and the children need to stay sheltered for a long period of time. A lockdown space in your home is where you can secure yourself and children from an intruder in your home for a long period of time.

Administering Prescription or Nonprescription Medication Record Form English / Spanish
By law, you must complete medication administration training in order to legally give medication to children in your care. You can use this 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.

Authorization for Emergency Medical Treatment English / Spanish
Parents fill out this form 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.

Injury or Accident Report English / Spanish
You can use this form to document injuries that occur to children while in care and share the information with parents.

Parent Notification of Allergic Reaction or Exposure English / Spanish
Allergic reaction or and exposure to an allergen is a real danger for children with allergies. You must notify parents if their child is exposed to an allergen even if there are no symptoms. This documents your contact with the parent, that you followed the allergic plan and that you have considered ways to prevent this in the future.

Parent Notification of Sick Child Care Policy English / Spanish
This policy outlines for parents your expectations of when a child can be in care and when a child is too sick to stay in care. Sick children who attend child care programs while contagious can make other children sick. Having a joint understanding helps parent prepare for when their child may need to be picked up from care due to illness.

Quick View Reference Sheet English / Spanish
The form captures all important medical information about medication allergies, food allergies, intolerances or dietary restriction on one form. You must post this information so that the information remains confidential and is kept out of view of others.

USDA Food Program Poster English / Spanish
Family child care providers who participate in the USDA Child and Adult Care Food Program must post one of these posters to notify parents that the provider participates in the program.

USDA Food Program Flyer for Parents English / Spanish
Family child care providers who participate in the USDA Child and Adult Care Food Program must give one of these flyers to each parent enrolled in the USDA Food Program.

Meal Guidelines
Meal Guidelines is set of food components, food items, and minimum quantities required for a breakfast, lunch, supper and snacks for a specific age group of children or infants. Select the meal guideline that corresponds with the age of the child in care.

Meal Guidelines for Infants 0-11 months English / Spanish
Meal Guidelines for Children 1-12 years English / Spanish

Neighborhood and Community Services

Alert:

Department Resources

Forms for Family Child Care Providers

Recent Interactions

Ask Fairfax

Neighborhood and Community Services

Alert:

Department Resources

Forms for Family Child Care Providers

Initial Application for Permit Forms

General Family Child Care Business Forms

Emergency Preparedness Forms

Medical Forms

USDA Child and Adult Care Food Program (CACFP)

Recent Interactions

Ask Fairfax