Indiana Form 50548 Home Consent printable pdf download

Indiana Form 50548 Home Consent

LICENSED CHILD CARE CENTER / HOME CONSENT

State Form 50548 (R2 / 7-06) / BCC 0080

To:

Parents of licensed child care programs in Indiana

Subject: Your child’s birth certificate and licensed child care programs

Indiana Code 12-17.2-2-1(8) requires each child care center or child care home to record proof of a child’s date of birth before accepting

the child for care. A child’s date of birth may be proven by the child’s original birth certificate or other reliable proof of the child’s date of

birth, including a duly attested transcript of a birth certificate. Refusing to share this information may result in your child’s exclusion from

a licensed child care program. Sharing the birth certificate information is NOT optional; signing the below is your decision and does not

impact your use of child care facilities.

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LICENSED CHILD CARE CENTER / HOME CONSENT

State Form 50548 (R2 / 4-06) / BCC 0080

This portion is to be kept on file at the licensed child care program.

I give my permission for ____________________________________________________________ to report the name and date of birth

name of licensed child care program

of my child or children to the Division of Family Resources pursuant to IC 12-17.2-2-1.5.

Name of child

Date of birth (month, day, year)

Name of child

Date of birth (month, day, year)

Name of child

Date of birth (month, day, year)

Name of child

Date of birth (month, day, year)

Signature of parent, guardian, or custodian

Date signed (month, day, year)

Indiana Form 50548 Home Consent