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 (PDF) (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)
• Consent for Emergency Medical / Dental (PDF)
• Crib Monthly Inspection Form (PDF)
• Crib Guide 2011 (PDF)
• Emergency Plan (PDF)
• Expedited Correction Order (PDF)
• Family Child Care Checklist (PDF)
• Field Trip Permission Form (PDF)
• Fire and Storm Drill Log (PDF)
• Fire Marshal Permission Form for Rental Property (PDF)
• Floor and Escape Plan (PDF)
• Furnace Inspection (PDF)
• Immunization Form (PDF)
• Infant Rolling (PDF)
• Liability Insurance Form (PDF)
• Licensing Requirement Dispute (PDF)
• Mandated Reporter Policy (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)
• Poisonous Plants (PDF)
  
• Program Grievance Procedure (PDF)
• Provider Policy Form (PDF)
• Requirements for Helpers / Subs / Second Adult (PDF)
• Rule Summary for Parents (PDF)
• Substitute Hours Tracking (PDF)
• SUIDS, Abusive Head Trauma, and Passenger Restraint Training Log (PDF) (optional form)
• Variance Request Extended Use of Substitute (PDF)
• Wading Pool Permission Form / Wading Pool Fact Sheet (PDF)
• Worksheet for Independent Study (PDF)