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Service Center Cottage Grove
13000 Ravine Parkway
Cottage Grove, MN 55016
Phone: 651-430-4159
Fax: 651-430-4157
Service Center Forest Lake
19955 Forest Road N
Forest Lake, MN 55025
Phone: 651-275-7260
Fax: 651-275-7263
Government Center
14949 62nd St N P.O. Box 30
Stillwater, MN 55082-0030
Phone: 651-430-6455
Fax: 651-430-6605
Service Center Woodbury
2150 Radio Drive
Woodbury, MN 55125
Phone: 651-275-8650
Fax: 651-275-8682
www.co.washington.mn.us
Washington County is an equal opportunity organization and employer
Community Services
EA-572
06/11
CHILD CARE ASSISTANCE PROVIDER FORM
To be completed by the provider. If you have questions about this form, please contact
at fax __________________.
II. Child Care Provider’s Name: ______________________________________________
Provider Address: ______________________________________________
______________________________________________
Provider County: ______________________________________________
Provider Phone #: ______________________________________________
Provider Social Security Number/Federal Tax ID #: _____________________________
Check the provider type:
Licensed family home: County licensed in __________________________
Care provided in my home; child’s home. DHS License # ______________
Licensed center – DHS License # ________________________________
Legal non-licensed provider (Please complete the attached Legal, Unlicensed Child Care
Provider Registration Application.)
Care provided in my home; child’s home.
Related to family? ______ yes ______ no
School district before/after school program School District # ____________
Are you accredited? Yes No ___ Type __________ Begin date _______ End date ________
II. Parents Name
__________________________________________
List the children for whom you provide care and the days/hours they are in your care.
Complete a separate line for each child.
Child’s Name Start Date Days in Care Time In Time Out
(M,T,W,TH,F,S,Su) (not hours of operation)
______________________ ___________ _________________ __________ ___________
______________________ ___________ _________________ __________ ___________
______________________ ___________ _________________ __________ ___________
______________________ ___________ _________________ __________ ___________
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