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Child Care Subsidy Services

Appendix A: Subsidized Child Care Forms

Appendix A: Subsidized Child Care Forms

The following forms are used in the administration of the Subsidized Child Care Services Program. Refer to http://info.dhhs.state.nc.us/olm/forms/dcd/ for copies of the forms.

Form Number

Current Revision Date

Title

DCD-0013

1/00

Copy of Requirements for Payment of Care in the Child’s Home

DCD-0037

3/96

Copy of Child’s Health/Emergency Information and Authorization Form for Transportation Providers

DCD-0038i

09/07

Copy of Requirements for Transportation Provider (Public and Private Agencies)

DCD-0039i

09/07

Copy of Requirements for Transportation Provider (Individual)

DCD-0040

9/09

Copy of Forms Request

DCD-0047

5/00

Copy of Sample Fingerprint Card

DCD-0048

5/00

Copy of Authority for Release of Information

DCD-0049

5/00

Copy of Notice of Child Care Provider Mandatory Criminal History Check

 

11/99

Criminal Records Background Checks Instructions for Potential Family Child Care Home Providers

 

5/00

Criminal Records Background Checks Instructions for Potential Owners/Operators of a Licensed Child Care Center

 

5/00

Criminal Records Background Checks Instructions for Regulated Programs

 

3/00

Criminal Records Checks Instructions for Nonlicensed Home and Transportation Only Providers

 

2/01

Criminal Records Background Checks Instructions for Summer Camp Operators

DCD-0050/0052

2/02

Copy of Criminal Records Check Identifying Information Form for Regulated Programs and Nonlicensed Homes

DCD-0093i

09/07

Copy of Referral for Child Care - Children with Special Needs

DCD-0094i

09/07

Copy of Approval of Supplemental Rate

DCD-0106i
English Spanish

8/07

Copy of Recipient Responsibilities for Subsidized Child Care Services

DCD-0351

10/98

Copy of Permission to Administer Medication

DCD-0376

1/00

Health Form for Children

DCD-0377i

09/07

Copy of Child's Health and Emergency Information for Family Child Care Homes

DCD-0404i

09/07

Copy of Application and Purchase Agreement for Child Care Transportation Services

DCD-0446i

07/09

Copy of Child Care Voucher and Instructions

DCD-0446-2i

07/09

Copy of Child Care Voucher Continuation Page

DCD-0450i

09/07

Copy of Child Care Action Notice and Instructions

DCD-0450-2i

09/07

Copy of Child Care Action Notice Continuation Page

DCD-0451i

09/07

Copy of Application for Enrollment to Be a Provider of Subsidized Child Care and Instructions

DCD-0452

04/13

Copy of Child Care Provider Agreement

DCD-0454Ai

09/07

Copy of Child with Special Needs Additional Expense Documentation

DCD-0454Bi

09/07

Copy of Provider Information Form

DCD-0455

4/01

Copy of Nonlicensed Home Checklist

DCD-0456
English Spanish

04/12

Copy of Application for Child Care Services and Instructions

DCD-0458i

09/07

Copy of Private Paying Rates and Other Fees and Instructions

DCD-0460

04/13

Copy of Information About Subsidized Child Care

SAMPLE

1/00

Copy of Children’s Medical Report

* In order to exhaust the current supply of this form, the DCD Distribution Center will send you an earlier version. It is acceptable to use the version supplied by the DCD Distribution Center.

 

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