Form 1860 "Child Care Provider Agreement," (May 2020) agreeing to the requirements set forth in He-C 6912.06(b)(4)a.-af.;and
"I understand the Division for Children, Youth and Families, Child Development Bureau will conduct a background check to include but not limited to: NH State Police Criminal Records (age 18 and older); Fingerprint-based criminal record check of the FBI national database (age 18 and older); check of the state and national sex offender registry and; a central registry for child abuse and neglect check (12 years or older) for every state lived in for the past 5 years. This is in accordance with RSA 170-E:3-a, 170-E;7 and federal laws (Adam Walsh Act and Megan's Law), and is required for all individuals who an employed or volunteer for licensed-exempt child care center, and who have contact with the children whose care I receive child care reimbursement from the Department.
I understand that the Division for Children, Youth and Families, Child Development Bureau shall check the National and State Sex Offender Registries, the DCYF Central Registry Name Search and the NH State Police Criminal Records and FBI database.
I understand that I am required to complete and submit a notarized NH Health and Human Services Criminal History Records Information Authorization (DSSP372) and a notarized DCYF Central Registry Name Search Authorization (Form 2503) and that my name will be received against the National and State Sex Offender Registries.
I understand that every member of my household, employee or volunteer age 12 and older will submit a notarized DCYF Central Registry Name Search Authorization (Form 2503) and their names will be reviewed against the National and State Sex Offender Registries.
I understand that every member of my household, employee or volunteer age 18 and older will submit a notarized NH Health and Human Services Criminal Record Information Authorization (DSSP372).
I understand that I am required to complete and submit any other background check information forms as required by any state that I have lived in during the past 5 years.
I understand that every member of my household, employee or volunteer age 18 and older is requested to complete and submit any other background check information forms as required by any state that they have lived in during the past five years.
I understand that I am required to complete and submit a new Background Check Information Form (2505) and all required authorizations on the first day that any information in this form changes. For example: someone moves into your home or begins to have contact with children.
I certify that all information on this form is true and complete. Providing falsified information may be grounds for denying enrollment".;
Department of Health and Human Services
DCYF Provider Relations
129 Pleasant Street
Brown Building 3rd Floor
Concord, NH 03301
Table 6912.1
Forms and Documentation Required for Protective Child Care Enrollment
Form or Document | Licensed | License-Exempt | Licensed Foster Parent |
Copy of current N.H. child care license | X | * | * |
Copy of current Foster Care license | * | * | X |
Form 1860 "Child Care Provider Agreement" (May 2020) | X | X | X |
Form 1862 "Child Care Provider Enrollment Form" (May 2020) | X | X | X |
"State of NH Alternate W-9 Form" (October 2016) | X | X | X |
Form 2679 "Provider Web-Billing User Account Request" (November 2016) | X | X | X |
"Form 2503 DCYF Central Registry Name Search Authorization" (October 2016) | * | X | * |
Form 2505 "Background Check Information and Authorization" (February 2017) | * | X | * |
DSS P372 "NH Health and Human Services Criminal History Record Information Authorization" (10/1/16) | * | X | * |
Health and Safety Training Documentation | * | X | * |
First Aid Certification for Pediatric | * | X | * |
Pediatric CPR Certification | * | X | * |
N.H. Admin. Code § He-C 6912.11