DEPARTMENT OF SOCIAL SERVICES NEW PROVIDER REGISTRATION REQUEST/REFERRAL
PART A. To be completed by the Parent, Guardian or Caseworker
Caseworker Name	CD FSD
Caseworker Telephone Number	Caseworker Fax Number
County, Office, or District Number
Parent/Guardian Name	Parent/Guardian Phone Telephone Number
Provide the names of Children needing child care.
Child	Date of Birth	DCN
PART B. To be completed by Child Care Provider
Provider Name	SSN	DVN
Provider Phone Telephone Number	Driver’s License Number
Provider Street Address
City, State, Zip
Check one of the following: A. This is a licensed facility OR an exempt school/faith based facility. B. I am age 18 or over and I will care for no more than 4 children plus my immediate relatives in the home.
If you checked B, list every person age 17 or older living or staying in your home.
Name	Social Security #	Date of Birth
After both Part A and B are filled out, mail or fax this page to your local Child Care Provider Relations Unit. (Addresses listed below)
St. Louis City Area Child Care Provider Relations Unit Prince Hall 4411 N. Newstead Avenue 3rd Floor St Louis, MO 63115-2547 Fax: 314-877-2684	Child Care Provider Relations Unit P.O. Box 88 Jefferson City, MO 65103 Fax: 573-526-9586
To find you local Child Care Provider Relations Unit go to http://www.dss.mo.gov/cd/childcare/pdf/ccpru-expansion.pdf.
OFFICE USE ONLY
This childcare provider has been assigned DVN #	effective
The childcare rates are effective beginning	.
If you are unable to authorize the children for the appropriate dates of service, please contact your supervisor.