Family Child Care Licensing Forms

Clay County Social Services makes available several child care licensing forms for use by licensed child care providers in Clay County. Return all required materials to your licensor at:

Clay County Social Services
715 11th Street N.
Suite 502
Moorhead, MN 56560

• Accident Report (PDF)
• Admission and Arrangement (PDF)
• Alcohol / Drug Use Policy (PDF)
• Allergy Information Form (PDF)
• Application – Family Child Care  (new and renewing providers)
• Certificate of Compliance - Minnesota Workers' Compensation Law (PDF)
• Child Care Activity / Travel Authorization (PDF)
• Child Care Reporting / Mandated Reporter Form (PDF)
• Commissioner’s Right of Access (PDF)
• Consent for Emergency Medical / Dental (PDF)
• Crib Monthly Inspection Form (PDF)
• Crib Guide 2011 (PDF)
• Emergency Plan (PDF)
• Enrollment (PDF)
• Expedited Correction Order (PDF)
• Field Trip Permission Form (PDF)
• Fire and Storm Drill Log (PDF)
• Floor and Escape Plan (PDF)
• Furnace Inspection (PDF)
• Immunizations (PDF)
• Infant Rolling (PDF)
• Liability Insurance Form (PDF)
• Licensing Requirement Dispute (PDF)
• Maltreatment of Minors Mandated Reporting (PDF)
• Notice of Privacy Rights (PDF)
• Parent Consent for Swaddling Infant (PDF)
• Permission to Administer Medication Form (PDF)
• Permission to Administer Over the Counter Items (PDF)
• Physician Directive for Alternative Infant Sleep Positions (PDF)
• Physician's Report (PDF)
• Variance for Physician Report not Signed by an MD (PDF)
• Program Grievance Procedure (PDF)
• Provider Policy Form (PDF)
• Requirements for Helpers / Subs / Second Adult
• Rule Summary for Parents (PDF)
• Swaddling Consent for an Infant (PDF)
• Substitute Hours Tracking (PDF)
• Variance Policy & Procedure (PDF)
• Variance Request (PDF)
• Variance Request Extended Use of Substitute (PDF)
• Wading Pool Permission Form (PDF)
• Wading Pool Fact Sheet (PDF)
• Worksheet for Independent Study (PDF)