Licensing Forms & Documents for Providers




To download a document, right-click the link to save it to your hard drive. You can also click the link directly to open it. Read the DEL licensing policies and procedures that guide our licensing work.

General Licensed Child Care Forms
Nonexpiring License
Nonexpiring licenses went into effect July 22, 2011.

Fast facts about nonexpiring licenses File Format: Adobe Acrobat (PDF) [709 k]
Declaration of Compliance File Format: Microsoft Word (DOC) [1.44k]
Background Check List for Family Homes File Format: Microsoft Word (DOC) [25k]
Background Check List for Centers and School-Age Programs File Format: Microsoft Word (DOC) [24k]
Background Check Form
Background check form for child care workers.

Background Check Form File Format: Microsoft Word (DOC)
Background Check Form File Format: Adobe Acrobat (PDF)
Background Check Form - Spanish Microsoft Word (DOC)
Background Check Form - Spanish File Format: Adobe Acrobat (PDF)

Certificate of Immunization Status Form
Washington State Department of Health Certificate of Immunization Status form.

Certificate of Immunization Status Form (English) File Format: Adobe Acrobat (PDF)
Certificate of Immunization Status Form (Spanish) File Format: Adobe Acrobat (PDF)

Certificate of Exemption

Certificate of Exemption (English) File Format: Adobe Acrobat (PDF)
Certificate of Exemption (Spanish) File Format: Adobe Acrobat (PDF)

Child Care Agreement
Financial agreement

Child Care Agreement File Format: Adobe Acrobat (PDF) [26k]
Child Care Agreement (Spanish) File Format: Adobe Acrobat (PDF) [31k]
Child Care Agreement File Format: Microsoft Word (DOC) [185k]
Child Care Agreement (Spanish) File Format: Microsoft Word (DOC) [188k]
Child Care Registration Form
Child Care Registration File Format: Adobe Acrobat (PDF) [41k]
Child Care Registration (Spanish) File Format: Adobe Acrobat (PDF) [41k]
Child Care Registration File Format: Microsoft Word (DOC) [219k]
Child Care Registration (Spanish) File Format: Microsoft Word (DOC) [219k]
Daily Attendance Records
Attendance record form for child care facilities.

Daily Attendance Records File Format: Adobe Acrobat (PDF) [244k]
Daily Attendance Records (Spanish) File Format: Adobe Acrobat (PDF) [244k]
Daily Attendance Records File Format: Microsoft Word (DOC) [81k]
Daily Attendance Records (Spanish) File Format: Microsoft Word (DOC) [81k]
Fire Safety
Fire Safety Record File Format: Adobe Acrobat (PDF) [202k]
Fire Safety Record (Spanish) File Format: Adobe Acrobat (PDF) [220k]
Fire Safety Record File Format: Microsoft Word (DOC) [208k]
Fire Safety Record (Spanish) File Format: Microsoft Word (DOC) [210k]
For more information, see the Office of the State Fire Marshal's page Fire Inspection Process for Child Care Centers
Child Injury/Incident Report
Injury/Incident Report File Format: Adobe Acrobat (PDF) [84k]
Injury/Incident Report (Spanish) File Format: Adobe Acrobat (PDF) [41k]
Injury/Incident Report File Format: Microsoft Word (DOC) [198k]
Injury/Incident Report (Spanish) File Format: Microsoft Word (DOC) [77k]
Proposed Capacity Determination
Form to calculate licensee capacity.

Proposed Capacity Determination File Format: Adobe Acrobat (PDF) [106k]
Proposed Capacity Determination File Format: Microsoft Word (DOC) [100k]
Recall Statement Form
A form agreeing to regularly review the information on the Consumer Products Safety Commission website or toll-free number and stay informed on items recalled due to hazard.

English File Format: Adobe Acrobat (PDF) [18k]
Spanish Adobe Acrobat (PDF) [20k]
Reconsideration Request Form
Reconsideration Request Form File Format: Adobe Acrobat (PDF) [33k]
Reconsideration Request Form File Format: Microsoft Word (DOC) [184k]
School-Based and Military Certification for Payment-Only Request Form
Form to request certification for payment only.

School Based and Military Certification for Payment Only Request Form File Format: Adobe Acrobat (PDF) [50k]
School Based and Military Certification for Payment Only Request Form File Format: Microsoft Word (DOC) [170k]
Tribal Certification Request Letter
Form to request Tribal certification for payment only.

Tribal Certification Request Letter Template File Format: Adobe Acrobat (PDF) [6k]
Tribal Certification Request Letter Template File Format: Microsoft Word (DOC) [41k]

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School-Age and Center Provider Forms
Child Care Center Director/Program Supervisor Notice of Change
Child care center or school age director/program supervisor notice of change.

Child Care Center Director/Program Supervisor Notice of Change File Format: Adobe Acrobat (PDF) [56k]
Child Care Center Director/Program Supervisor Notice of Change File Format: Microsoft Word (DOC) [184k]
Child Care Center Feasibility Checklist
Licensing checklist form for child care centers.

Child Care Center Feasibility Checklist File Format: Adobe Acrobat (PDF) [109k]
Child Care Center Feasibility Checklist File Format: Microsoft Word (DOC) [217k]
Child Care Center Full Checklist
Full licensing checklist form for child care centers.

Child Care Center Licensing Checklist File Format: Adobe Acrobat (PDF) [217k]
Child Care Center Licensing Checklist File Format: Microsoft Word (DOC) [681k]
Child Care Center Abbreviated Checklist
Abbreviated checklist form for child care centers.

Child Care Center Monitoring Checklist File Format: Adobe Acrobat (PDF) [217k]
Child Care Center Monitoring Checklist File Format: Microsoft Word (DOC) [681k]
Center Licensing Application
Licensing Application form for centers. You must attend DEL orientation before submitting a licensing application.

Center Licensing Application File Format: Adobe Acrobat (PDF) [223k]
Center Licensing Application File Format: Microsoft Word (DOC) [570k]
School-Age Licensing Application
Licensing Application form for school-age facilities and programs. You must attend DEL orientation before submitting a licensing application.

School-Age Licensing Application File Format: Adobe Acrobat (PDF) [347k]
School-Age Licensing Application File Format: Microsoft Word (DOC) [570k]
Center and School-Age Application for Employment
Application for Employment in a licensed child care facility.

Center/SA Application for Employment File Format: Adobe Acrobat (PDF) [174k]
Center/SA Application for Employment File Format: Microsoft Word (DOC) [360k]
Center File Review Checklist
File review checklist form for child care centers.

Center File Review Checklist File Format: Adobe Acrobat (PDF) [107k]
Center File Review Checklist File Format: Microsoft Word (DOC) [202k]
Center Probation Notification Letter to Parents
Letter to inform parents the center is operating with a probationary child care license under the following conditions.

Center Probation Notification Letter to Parents File Format: Adobe Acrobat (PDF) [35k]
Center Probation Notification Letter to Parents File Format: Microsoft Word (DOC) [38k]
School-Age Full Checklist
Full licensing checklist form for School-age Programs.

School-Age Licensing Checklist File Format: Adobe Acrobat (PDF) [210k]
School-Age Licensing Checklist File Format: Microsoft Word (DOC) [480k]
School-Age Abbreviated Checklist
Abbreviated licensing checklist form for School-age Programs.

School-Age Monitoring Checklist File Format: Adobe Acrobat (PDF) [210k]
School-Age Monitoring Checklist File Format: Microsoft Word (DOC) [480k]

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Family Home Provider Forms
Family Home Liability Insurance Exemption
A form regarding insurance status.

Insurance Notification File Format: Adobe Acrobat (PDF) [8k]
Insurance Notification File Format: File Format: Microsoft Word (DOC) [24k]
Family Home Licensing Application
Licensing Checklist form for Family Home Child Care. You must attend DEL orientation before submitting a licensing application.

Licensing Application form for Family Home Child Care File Format: Adobe Acrobat (PDF) [250k]
Licensing Application form for Family Home Child Care (Spanish) File Format: Adobe Acrobat (PDF) [250k]
Licensing Application form for Family Home Child Care File Format: Microsoft Word (DOC) [280k]
Licensing Application form for Family Home Child Care (Spanish) File Format: Microsoft Word (DOC) [280k]
Family Home Full Checklist
Full licensing checklist form for Family Home Child Care.

Family Home Licensing Checklist File Format: Adobe Acrobat (PDF) [250k]
Family Home Licensing Checklist File Format: Microsoft Word (DOC) [280k]
Family Home Monitoring Checklist
Abbreviated licensing checklist form for Family Home Child Care monitoring visits.

Family Home Monitoring Checklist File Format: Adobe Acrobat (PDF) [181k]
Family Home Monitoring Checklist File Format: Microsoft Word (DOC) [280k]
Family Home Permission Authorization
Parent/guardian permission authorization form for family home child care.

Family Home Permission Authorization File Format: Adobe Acrobat (PDF) [37k]
Family Home Permission Authorization (Spanish) File Format: Adobe Acrobat (PDF) [37k]
Family Home Permission Authorization File Format: Microsoft Word (DOC) [42k]
Family Home Permission Authorization (Spanish) File Format: Microsoft Word (DOC) [42k]
Family Home Probation Notification Letter to Parents from Provider
Parent/guardian permission authorization form for family home child care.

Probation Notification Letter File Format: Adobe Acrobat (PDF) [35k]
Probation Notification Letter File Format: Microsoft Word (DOC) [34k]
Family Home Provider/Assistant Resume Form
Provider/assistant resume form for family home child care.

Family Home Provider/Assistant Resume Form File Format: Adobe Acrobat (PDF) [55k]
Family Home Provider/Assistant Resume Form (Spanish) File Format: Adobe Acrobat (PDF) [38k]
Family Home Provider/Assistant Resume Form File Format: Microsoft Word (DOC) [99k]
Family Home Provider/Assistant Resume Form (Spanish) File Format: Microsoft Word (DOC) [243k]
Family Home Request to Change Capacity
Family child care capacity change request form.

Family Home Request to Change Capacity File Format: Adobe Acrobat (PDF) [158k]
Family Home Request to Change Capacity (Spanish) File Format: Adobe Acrobat (PDF) [158k]
Family Home Request to Change Capacity File Format: Microsoft Word (DOC) [228k]
Family Home Request to Change Capacity (Spanish) File Format: Microsoft Word (DOC) [228k]
Family Home Plan to Meet the Special Needs of an Individual Child
Form to request a special needs accommodation for a child in care.

Plan to Meet the Special Needs of an Individual Child File Format: Adobe Acrobat (PDF) [75k]
Plan to Meet the Special Needs of an Individual Child File Format: Microsoft Word (DOC) [75k]
Family Home Written Plan for Bodies of Water
Plan for bodies of water outside or near licensed space.

Family Home Written Plan for Bodies of Water File Format: Adobe Acrobat (PDF) [184k]
Family Home Written Plan for Bodies of Water File Format: Microsoft Word (DOC) [57k]
Family Home Written Plan for Dangerous or Aggressive Pet or Animal
Plan for keeping dangerous or aggressive pets or animals inaccessible to children.

Family Home Written Plan for Dangerous or Aggressive Pet or Animal File Format: Adobe Acrobat (PDF) [175k]
Family Home Written Plan for for Dangerous or Aggressive Pet or Animal File Format: Microsoft Word (DOC) [54k]
Family Home Written Plan for Licensee Absence
Staffing plan during licensee's absense.

Family Home Written Plan for Licensee Absence File Format: Adobe Acrobat (PDF) [320k]
Family Home Written Plan for Licensee Absence File Format: Microsoft Word (DOC) [73k]
Family Home Multiple Licenses Request Form
Form to request multiple family home licenses.

Family Home Multiple Licenses Request Form File Format: Adobe Acrobat (PDF) [249k]
Family Home Multiple Licenses Request Form File Format: Microsoft Word (DOC) [152k]
Family Home Off-Site Permission Authorization for Occasional Trips
Form for parents or guardians to grant permission for off-site trips.

Family Home Off-Site Permission Authorization for Occasional Trips File Format: Adobe Acrobat (PDF) [78k]
Family Home Off-Site Permission Authorization for Occasional Trips (Spanish) File Format: Adobe Acrobat (PDF) [78k]
Family Home Off-Site Permission Authorization for Occasional Trips File Format: Microsoft Word (DOC) [51k]
Family Home Off-Site Permission Authorization for Occasional Trips (Spanish) File Format: Microsoft Word (DOC) [51k]
Family Home Inspection of Fireplaces, Wood Stoves, or Similar Wood-Burning Heating Devices
Compliance form for use of fireplaces, wood stoves, or similar wood-burning heating devices.

Family Home Inspection of Fireplaces, Wood Stoves, or Similar Wood-Burning Heating Devices File Format: Adobe Acrobat (PDF) [102k]
Family Home Inspection of Fireplaces, Wood Stoves, or Similar Wood-Burning Heating Devices File Format: Microsoft Word (DOC) [66k]
Family Home Request for Fire Department Visit
Form for requesting fire department visit.

Family Home Request for Fire Department Visit File Format: Adobe Acrobat (PDF) [129k]
Family Home Request for Fire Department Visit File Format: Microsoft Word (DOC) [177k]
Family Home Declaration of Items in Unlicensed Space
Form to declare certain items in unlicensed space in the family home.

Family Home Declaration of Items in Unlicensed Space File Format: Adobe Acrobat (PDF) [111k]
Family Home Declaration of Items in Unlicensed Space File Format: Microsoft Word (DOC) [1481k]
Family Home Medication Log
Form to log medication use for individual child in care.

Family Home Medication Log File Format: Adobe Acrobat (PDF) [206k]
Family Home Medication Log File Format: Microsoft Word (DOC) [74k]
Family Home Medication Permission Form
Form to obtain permission from parent or guardian to administer medication.

Family Home Medication Permission Form File Format: Adobe Acrobat (PDF) [244k]
Family Home Medication Permission Form File Format: Microsoft Word (DOC) [67k]
Family Home No Social Security Card Declaration Form
Form to declare the licensing applicant does not have a Social Security card.

Family Home No Social Security Card Declaration Form File Format: Adobe Acrobat (PDF) [44k]
Family Home No Social Security Card Declaration Form File Format: Microsoft Word (DOC) [1481k]
Family Home Overnight Care Request
Form to request approval to provide overnight care.

Family Home Overnight Care Request File Format: Adobe Acrobat (PDF) [285k]
Family Home Overnight Care Request File Format: Microsoft Word (DOC) [191k]
Family Home Safety Record and Evacuation Plan
Form to track monthly fire drill record, smoke and carbon monoxide detector record and quarterly disaster drills.

Family Home Safety Record and Evacuation Plan File Format: Adobe Acrobat (PDF)
Family Home Safety Record and Evacuation Plan File Format: Microsoft Word (DOC)

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STARS and MERIT Forms
STARS
View STARS/MERIT forms.

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News and information
Directors List of Crimes and Negative Actions
List of crimes that permanently disqualify an individual to have unsupervised access to children; and crimes that disqualify a person to have unsupervised access to children until five years have passed since the date of the conviction.
Employment of Blind and Visually Impaired [146k]
File Format: Adobe Acrobat (PDF)
Memorandum of Understanding to clarify the Department's policy as to the employment of blind and visually impaired workers at child care facilities.
Electronic Licensing Forms Frequently Asked Questions [89k]
File Format: Adobe Acrobat (PDF)
A question and answer document about DEL's electronic licensing forms.
Shortage of Syrup of Ipecac [70k]
File Format: Adobe Acrobat (PDF)
Notice to providers explaining the shortage of Ipecac in Washington State.
Window Blind Information
Questions and answers on use of window coverings in licensed child care in accordance with RCW 43.215.360.
July 2008 Frequently Asked Questions on State Window Blind Cord Law File Format: Adobe Acrobat (PDF) [139k]
July 2008 Frequently Asked Questions on State Window Blind Cord Law (Spanish) File Format: Adobe Acrobat (PDF) [40k]
Window Blind Letter to Child Care Providers (April 2008) File Format: Adobe Acrobat (PDF)[74k]

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