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Child Care Enrollment and Fee Verification Form


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!

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