Licensing Interest Form Thanks for your interest! Please complete this form. You can expect a response from us within two business days. Question Title * 1. Select the county where the program will be located: Becker Cass Crow Wing Douglas Morrison Otter Tail Stevens Todd Wadena Question Title * 2. What type of license program are you pursuing: family child care or adult foster care? Family child care Adult foster care Question Title * 3. If you are interested in an adult foster care license, do you plan to pursue a 245d license as well? Yes No Not pursuing an adult foster care license Question Title * 4. Have you been licensed before? Yes No Question Title * 5. Why are you pursuing a license for family child care or adult foster care? Question Title * 6. Do you need interpreter services? Yes No If yes, please specify language. Question Title * 7. Do you have any Hispanic heritage?The county licensing system we use requires this information, it's part of its audit requirement. Yes No Question Title * 8. Full name: Question Title * 9. Phone number: Question Title * 10. Email: Question Title * 11. What question(s) do you have about becoming a licensed provider? Question Title * 12. If you are planning to pursue a family child care license, we are seeking your permission to share your contact information (name, county, phone number, and e-mail address) to the Wayfinder Navigators to help you navigate the resources as a potential applicant. By selecting, yes, you are giving us permission to share your contact information to the designated Wayfinder Navigator. By selecting, no, we will not refer your contact information. Yes No Question Title * 13. If you are planning to pursue a family child care license, we are seeking your permission to make a referral with your contact information (name, county, phone number, and email address) to the Workforce Advisor through Empower to Educate to help you navigate and register for the required professional development as a family child care applicant. By selecting, yes, you are giving us permission to share your contact information to the designated Workforce Advisor and they will be reaching out to you by email once you have submitted your applicant packet. By selecting no, we will not refer your contact information. Yes No Done
