Day Care Registration

Provider Information

Name (required)

Email (required)

Address (required)

Telephone (required)

Signature (required)

Date (required)

Owner of Record of Subject Property

Name (required)

Email (required)

Address (required)

Telephone (required)

Signature (required)

Date (required)

Child Information

Number of children cared for (required)
Do not include children related to resident household
 Four to Six Seven to Twelve Twelve or More

Number children under 2 ½ years (required)

Names and addresses of caregivers not living in household
Family and Group Day Care Only

Name

Telephone

Address

Name

Telephone

Address

PA. Department of Public Welfare approval

Date (required)

Attach copy

Name and telephone number of person to contact in an emergency

Name (required)

Telephone (required)

Address (required)

Name

Telephone

Address