Family Child Care Sample Forms Packet Page 3
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12Changes in Household Composition
If there are any changes in your household during the three (3) year licensing period (including
but not limited to new baby, adopted child, foster children, visiting relative, or any person who will
reside in your home for more than 30 days) you must submit the following required information to
EEC:
Educator’s Name:_____________________________________________________________________
Address:___________________________________________________________________________
Date of license expiration:___________________________
Program ID#____________________________________
ADDITION TO HOUSEHOLD:
Name _____________________________________ Date of Birth _________________________
Relationship ________________________________
Number of hours at home
during the child care day ______________________
Name _____________________________________ Date of Birth _________________________
Relationship ________________________________
Number of hours at home
during the child care day ______________________
Name _____________________________________ Date of Birth _________________________
Relationship ________________________________
Number of hours at home
during the child care day ______________________
NOTE: Any person 15 years of age or older must also complete and submit a Background Record
Check form.
PLEASE REMEMBER TO ALSO NOTIFY PARENTS OF ANY CHANGE IN HOUSEHOLD COMPOSITION.
Page 3 of 12
FCCSampleFormPacket20100203
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