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Indiana Child Care Provider Forms
Licensed Centers
Application for Child Care Center Variance or Waiver
Application for Construction Permit for Child Care Facility - State Form 49454
Attestation Statement - State Form 48629/BCC 0012
Breast milk Procedure 49954 (R/12-06)/BCC 0067
Consent to Release Information for Licensed Centers, Licensed Homes, Unlicensed Registered Ministries, and CCDF LLEPs - State Form 53323 (R2/3-10) / BCC 0330
Health Care Program for Child Care Centers: Child Care Center Health Record - State Form 49969 (R2/11-06)/ BCC 0019
Healthcare Program for Childcare Centers - State Form 45877/BCC 0054
Healthcare Program for Childcare Centers Suggested First Aid Directives - Part of State Form 45677
History of Immunizations - State Form 49445/BCC 0036
Injury Report Form for Licensed Child Care Centers
Licensed Child Care Center / Home Consent - State Form 50548(R2/7-06)/BCC 0080
Monthly Report of Licensed Child Care Centers and Homes (As Required
by IC 12.17.2-2-1.5) - State Form 46789 (R/10-09)/BCC 0007
Provider Response Form - State Form 53320 (7-07) BCC 0312
Request for Limited Adult Criminal History Information - State Form 53320
Review / Assessment for Child Care Centers 46153 (R3/7-07)BCC 0320
Safe Transportation of Food Responsibility Agreement
Sample Intake Agreement Form
Sample New Employee Orientation Form
Sanitation/Sterilization Procedures for Bottles, Nipples, Collars, Caps 49953 (R2/12-06)/BCC 0066
Sanitizing Solutions 49973/BCC 0024
Supplement to Health Program Form - Infant/Toddler 45878/BCC 0055
Taxpayer Identification Number Request (W-9) 23743
Training Record Log
Verification and Documentation of Universal Precautions Training Form
Written Nutrition Food Service Program for Child Care Centers 46684/BCC 0051
Written Nutrition Food Service Program Infant/Toddler Child Care Centers 46682/BCC 0053
Licensed Homes
Application for Child Care Home Variance or Waiver 48269 (R/6-07)/BCC 0025
Attestation Statement 48629/BCC 0012
Breast milk Procedure 49954 (R/12-06)/BCC 0067
Child Care Home Injury Report (Medical Attention Needed) State Form 54265 (5-10) / BCC 0221
Child Care Home Licensing Report - State Form 46739 (R2/3-05)/ BCD 0011
Consent to Release Information for Licensed Centers, Licensed Homes, Unlicensed Registered Ministries, and CCDF LLEPs - State Form 53323 (R2/3-10) / BCC 0330
Healthcare Program for Childcare Centers 45877/BCC 0054
History of Immunizations 49445/BCC 0036
Licensed Child Care Center / Home Consent - State Form 50548(R2/7-06)/BCC 0080
Monthly Report of Licensed Child Care Centers and Homes (As Required by IC 12-17.2-2-1.5) - State Form 46789 (R/10-09)/BCC 0007
PTQ Voluntary Decline Form
Provider Response Form - State Form 53320 (7-07) BCC 0312
Sanitizing Solutions 49973/BCC 0024
Taxpayer Identification Number Request (W-9) 23743
Verification and Documentation of Universal Precautions Training Form
Registered Ministries
Application for Voluntary Certificate of Recognition 49443/BCC 0034
Attestation Statement 48629/BCC 0012
Breast milk Procedure 49954 (R/12-06)/BCC 0067
Checklist For Registered Child Care Ministries Sanitation Survey 49441 (R5/9-07)/BCC 0032
Child Care Development Fund (CCDF) Provider Eligibility Standards (PES) Checklist, State Form 51363/BCC 0091
Consent to Release Information for Licensed Centers, Licensed Homes, Unlicensed Registered Ministries, and CCDF LLEPs - State Form 53323 (R2/3-10) / BCC 0330
History of Immunizations 49445/BCC 0036
PTQ Voluntary Decline Form
Parent's Notice 49444/BCD 0035
Provider Response Form - State Form 53320 (7-07) BCC 0312
Request for Limited Adult Criminal History Information -State Form 8053
Sanitation/Sterilization Procedures for Bottles, Nipples, Collars, Caps 49953 (R2/12-06)/BCC 0066
Sanitizing Solutions 49973/BCC 0024
Taxpayer Identification Number Request (W-9) 23743
Verification and Documentation of Universal Precautions Training Form
LLEP's (Legally Licensed-Exempt Providers)
Child Care Development Fund (CCDF) Provider Eligibility Standards (PES) Checklist, State Form 51363/BCC 0091
Consent to Release Information for Licensed Centers, Licensed Homes, Unlicensed Registered Ministries, and CCDF LLEPs - State Form 53323 (R2/3-10) / BCC 0330
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