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Divisions
Divisions > Early Childhood Development > Licensing
Forms

Licensing Forms


 

The forms listed below are in .pdf format. You will need the Adobe Acrobat Reader to view them. If you do not already have the Reader, click the image.

get acrobat reader

After the title/description of each form, the following indicators are used to show what type of child care facility the form is used for:
  • (HOME/LFCCH) - family child care homes (small) and large family child care homes
  • (HOME) - family child care homes (small) only
  • (LFCCH) - large family child care homes only
  • (CTR/LOC) - child care centers and letter of compliance facilities
  • (CTR) - child care centers only
  • (LOC) - letter of compliance facilities only
  • (ALL) - centers, homes (small and large), and letter of compliance facilities 

    NOTE:  Each of the forms listed below on this page can only be completed manually.  First, open a form up by clicking on its highlighted number; next, print the form out; and then fill in the required responses by hand (or on a typewriter).  Finally, mail to the appropriate OCC Regional Licensing Office via the U.S Postal Service.  If you wish to complete these forms electronically, click here to access fill-in enabled versions of the forms.

    If you have any questions about the use of a form, please contact your Regional Licensing Office.


    Form Number Title/Description
     
    Allergy Action Form
       
      Asthma Action Form
       
    DHMH 896 Immunization Certificate (ALL)
     
    100   Professional Development Plan (LFCCH, CTR)

    101A Professional Development Plan-1st Year(HOME)

    101B  Professional Development Plan-Continuing (HOME/LFCCH)

    101C 

    FDC Applicant – Initial Training Requirements (HOME/LFCCH)

    349 Application to Resume Service (HOME)
     
    356 Family Child Care Home Inspection Report (HOME)
     
    672 Request for Continuing License or Letter of Compliance (CTR/LOC)

    673 Request for Continuing Registration (HOME)

    674 Checklist for 24-Month Submission of Information (ALL)

    1200 Application - Initial (CTR/LOC)
     
    1201 Insurance Information (LFCCH, CTR/LOC)
     
    1203 Personnel List & Staff Change Report (LFCCH, CTR/LOC)
     
    1204 Medical Report for Child Care (ALL)
     
    1205 Personnel Information (LFCCH, CTR)
     

    1206

    Staffing Pattern (LFCCH, CTR/LOC)

    1207           Personnel Qualification Evaluation
                     (LFCCH, CTR)


    1209 Changes in Facilities (LFCCH, CTR/LOC)
     
    1210-A Letter of Compliance Inspection Report (LOC)
     
    1213 Variance Request (ALL)
     
    1214 Emergency Form (ALL)
     
    1215 Health Inventory (ALL)
     
    1216 Medication Administration Authorization (ALL)

    1218 Menu Plan (LFCCH, CTR/LOC)
     
    1229 Substitute Form (HOME/LFCCH)
     
    1230 Application - Initial (HOME)
     
    1255 Child Care Center Inspection Report (CTR)
     
    1260 Release of Information (ALL)

    1261 Emergency Escape Plan (HOME)
     
    1267 Provider Information & Plan of Operation (HOME)
     
    1268 Environmental Health Survey (ALL)
     
    1270 Notice of Intent to Operate (CTR/LOC)
     
    1275 Additional Adult Application (HOME)
     
    1281 Request for Hearing (ALL)
     
    1285 Health History - Drop -in (CTR)
     
    1295

    Self-Assessment Guide (HOME)




  • Contact Information
    Maryland State Department of Education
    200 West Baltimore Street
    Baltimore, MD 21201
     Licensing Branch
    Regional Licensing Offices
    Finding the Right Child Care
    Parent's Guide to Regulated Care
    Una Guía para Padres (en español)
    Opening a Child Care Center
    Opening a Family Child Care Home
    Provider Grant Program
    Partners Newsletter
    Circular Letters
    Forms
    Formularios de Licencia (en español)
    Resource Documents
    Enforcement Actions and Appeals
    Regulations
    On-Line Licensing Inspection Results
     Office of Child Care
    Licensing Branch
    Child Care Subsidy Branch (Purchase of Care Program)
    Program Development Branch
    Credentialing Branch
    Grants Programs
    Child Care Resource Centers
    Guidelines - Healthy Child Development
    Early Childhood Curriculum Project
    Issues / Complaints
    CCATS - Child Care Automated Tracking System
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