Common Provider Forms

Below is a list of commonly used child care provider forms. Please contact Choices CCR&R with any questions.

Child Care Parent Fee Notice (ECE-CC-10D)
Child Care Provider Request for Payment (ECE-10A)
Child Care Attendance Sheet (ECE-CC-10G)
Child Health Assessment
Child Emergency Information
Emergency Phone List
Emergency Plan
Fire Escape Plan
Incident Report Form
Medical Permission Slips
Pet Acknowledgement Form
Provider Medical Report Form (Registered/Subsidized Family Child Care Providers)
Provider Notice to Agency
Provider Training Record
Statement of Good Health (Informal/Relative Child Care Providers)

Direct Deposit Information

Effective January 1, 2007 Direct Deposit will be available for Child Care Providers. Click here for more information or contact the state auditors office at 304-558-2251. All forms are listed below.


FACTS PLUS allows registered Providers to view information about their services provided via Statewide FACTS system. If you are providing services to West Virginia clients through the FACTS System , you may request a Facts Plus Form. You will be notified about your application once it has been evaluated by FACTS Staff.