Child Care Facility Application

Child Care Application Form

Lead Testing in Schools and Child Care Facilities Drinking Water (LWSC) Program Child Care Application Form.

Licensed Child Care Facility Name(Required)

Choose a county and city to select a licensed child care facility. To nominate a private, in-home, licensed childcare facility, use the “nominate a facility” form.

Physical Street Address

Street Address City ZIP / Postal Code

Mailing Address

Street Address City ZIP / Postal Code

Superintendent Name

First Last

Superintendent Phone Numer

Superintendent Email Address

Principal Name

First Last

Principal Phone

Principal Email

Maintenance / Sampling Coordinator Name

First Last

Maintenance / Sampling Coordinator Email

Maintenance / Sampling Coordinator Phone