Name and Telephone Number Address Who are you representing? 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Provider Name' in the designated field. This identifies the child care provider associated with the waiver request.
3. Next, input the 'Provider ID #' to ensure accurate identification within the licensing system.
4. Fill in the 'Mailing Address', including 'City', 'State', and 'Zip Code'. This information is crucial for correspondence regarding your waiver request.
5. Enter your 'Telephone' number and 'Email' address for any follow-up communications from DCYF.
6. Select the appropriate 'Program Type' by checking all that apply. This helps categorize your request accurately.
7. In the 'Waiver Request Details' section, specify the WAC number and provide a detailed explanation of why you are requesting this waiver, ensuring clarity on specific needs.
8. Describe how you will maintain health, welfare, and safety standards if your waiver is approved. Attach additional pages if necessary.
9. Finally, sign and print your name along with the date before submitting it to your local DCYF child care licensing office.

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