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Divisions > Early Childhood Development > Licensing

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.

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

    Form Number Title/Description
    DHMH 896 Immunization Certificate (ALL)
    100 Record of Professional Development Coursework (All)
    101 Record of Pre-Service Training for Family Child Care
    200 Application to Operate An Educational Program-Nonpublic Nursery School
    201 Nonpublic Nursery School Personnel Record
    349 Application to Resume Service (Family)
    672 Child Care Center Request for Continuing License or LOC
    673 Family Home Request for Continuing Registration
    675 Large Family - Request for Continuing Registration
    1200 Child Care Center Application for License–LOC
    1201 Worker's Compensation 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)


    Staffing Pattern (LFCCH, CTR/LOC)


    Personnel Qualification Evaluation
    (LFCCH, CTR)

    1209 Changes in Facilities (LFCCH, CTR/LOC)
    1213 Variance Request (ALL)
    1214 Emergency Form (ALL)
    1215 Health Inventory (ALL)
    1216 Medication Administration Authorization (ALL)

    1216A Seizure Medication Administration Authorization (ALL)


    Medication Incident Reporting Form
    1218 Menu Plan (LFCCH, CTR/LOC)
    1229 Substitute Form (HOME/LFCCH)
    1230 Family Child Care Home Application
    1240 Large Family Child Care Home Application
    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)

    Self-Assessment Guide (HOME)

      Accident/Injury Record (ALL)
      Allergy Action Form
      Asthma Action Form
      Checklist-Application for Resumption of Service (Family Child Care Registration Only)
      Checklist-Application for NonPublic Nursery School
      Checklist-Continuing Application-Center-LOC
      Checklist-Continuing Application-Family Child Care Registration
      Checklist-Continuing Application-Large Family Child Care Home
      Checklist-Initial Application-Child Care Center License or LOC
      Checklist-Initial Application-Family Child Care Registration
      Checklist-Initial Application-Large Family Child Care Home
    Child Death or Serious Incident Report Form (ALL)
      Daily Attendance Record (ALL)
      Disaster Drill Record (ALL)
      Emergency Information Form (ALL)
      Fire Drill Record (ALL)
      Infant Toddler Daily Food Intake and Activities (ALL)
      Infant Toddler Orientation Checklist (HOME)
      On Call Agreement (LFCCH, CTR/LOC)
      Permission Slip – Offsite Activities (ALL)
      Permission Slip - Swimming/Wading Activities (ALL)
      Staff Orientation Verification (LFCCH, CTR/LOC)
      Substitute Orientation Verification (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
    Formularios de Licencia (en español)
    Resource Documents
    Enforcement Actions and Appeals
    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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