"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), as is required for all individuals who reside in my home, and other individuals not living in the home who have contact with the children for 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."; or
"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".
"The home has working smoke detectors and fire extinguishers on all floors.
The child care provider does not use corporal punishment. Corporal punishment means the use of physical force, physical restraint, or physical actions against a child as a means of discipline.
The child care provider will allow the parent or guardian unlimited access to the children while in his/her care.
The child care provider must be free of communicable diseases; be physically able and mentally capable of caring for the children.
The home has been checked (including indoor care areas and yard, and is safe for children. Children are protected from dangers such as standing bodies of water including pools and spas, electrical outlets, stairs, poisonous materials, medications, guns, and ammunition. A self-assessment checklist is available at http://nh.childcareaware.org/wp-content/uploads/2018/09/LE-FFN-Self-Check-List.pdf.
The provider has access to a telephone communications and emergency telephone numbers are readily accessible.
Provider's Statement: I certify all information provided and contained on this form are true and accurate to the best of my knowledge. If I am providing child care to a related child in my home, I certify that my home meets the basic health and safety requirements listed in Section 3. I understand that health and safety training resources are available at www.nh.childcareaware.org.
Parent/Guardian's Statement: I have approved the person named on this form to care for my children. I understand all information provided and contained on this form are true and accurate to the best of my knowledge. I understand that it is my responsibility to make sure the child care provided to my children and the place where care is provided is safe. I understand that the State of NH will not monitor the safety of the child care provided. I take full responsibility for the child care provided by this child care provider."
Department of Health and Human Services
Bureau of Child Development and Head Start Collaboration
129 Pleasant Street
Concord, NH 03301
Table 6914.1
Forms and Documentation Required for Enrollment
Employment Related Child Care | ||
Form or Document | Licensed | License-Exempt |
Copy of current N.H. child care license | X | |
Form 1860 "Child Care Provider Agreement" (April 2020) | X | X |
Form 1862 "Child Care Provider Enrollment Form" (April 2020) | X | X |
"State of NH Alternate W-9 Form" (October 2016) | 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 6914.04