Lorain County Department of Job and Family Services 2026

1. Click ‘Get Form’ to open the Withdrawal/Disenrollment Form for Child Care in the editor.
2. Begin by entering the 'Attention Child Care Worker' name at the top of the form. This ensures that your submission is directed to the appropriate individual.
3. Fill in the 'Center Name' and 'Provider #' fields to identify your facility clearly.
4. Input the 'Parent’s Name' and their 'SSN' if there is no case number available. This information is crucial for processing.
5. List each child's name under 'Child(ren)’s Name(s)' to specify who is being withdrawn from care.
6. Indicate the 'Last Day of Attendance' using the format Month/Date/Year, ensuring accurate record-keeping.
7. If applicable, detail any delinquent co-payments by listing the month/year and amount owed in the designated section.
8. Provide a reason for withdrawal if known, as this can help improve services in the future.
9. Ensure both 'Center Signature' and 'Parent Signature' are completed along with their respective dates before submission.
10. Submit the completed form to the LCDJFS Child Care Unit within 7 days of withdrawal to comply with regulations.

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