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Child Care Enrollment and Fee Verification Form

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This form is to be completed by the director of the child care center or the child care provider and returned with the completed application.

Provider Information

Note: Providers must have permanent license and be in good standing with KDHE.

Do you accept DCF funds?
Do you check e-mail regularly?
Enrollment Information (via provider)
Is child enrolled in full-time care?
Tuition Charged
Child Care Center or Family Child Care Provider Responsibilities

I certify that the information listed above is accurate to the best of my knowledge and that this child is enrolled in care.

Thanks for submitting!