Lic 9040-2026

1. Click ‘Get Form’ to open the lic 9040 in the editor.
2. Begin by entering the 'Facility Name' and 'Facility License Number' at the top of the form. This information identifies your child care facility.
3. In the 'Child’s Name/Birthdate' section, list each child's full name along with their birthdate. Ensure accuracy for proper record-keeping.
4. Fill in the 'Address' field for each child, providing their home address to maintain updated contact information.
5. Next, enter the names of the parent(s) or guardian(s) in the 'Parent/Guardian Name(s)' section, followed by their daytime phone numbers for easy communication.
6. Document the 'Physician Name and Phone' to ensure that emergency contacts are readily available.
7. Finally, include dates for when each child was enrolled and when they left, if applicable. This helps maintain an accurate roster over time.

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