Childcare Facility Application

Childcare Application Form

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

Licensed Childcare Facility Name(Required)

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

Physical Street Address

Street Address City State ZIP Code

Mailing Address

Same as previous

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