MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION WAIVER REQUEST FORM
Worker Information
Agency/County	Name of Worker	Authorizing Worker User ID/Worker #
Worker's Telephone Number	Worker's Fax Number	Worker's Email Address
Name of Supervisor
Child Information
Name of Child	Child's Date of Birth	Child's DCN	Child's Functional Age
Resource Parent Information
Is the location of the Resource Parent(s) in the same city as their residence while child is in care? Yes No If no, provide the location of Resource Provider's Residence: Location of Resource Provider while child is attending child care:
Attempt to Locate Licensed Care
Attempts made to secure licensed/contracted child care: Reviewed MOHSAIC Check all that apply Contacted the Local Child Care Resource and Referral Agency Contacted appropriate providers for availability Other (Explain below) Additional attempts made:
Extenuating and Mitigating Circumstances (NOTE: Preference and Convenience do not justify a waiver.)
Select Circumstance(s): Provider capacity No licensed/contracted provider available in geographic area Provider unable to meet child's needs Transportation Court ordered Chosen provider has a previous relationship with the child Other Additional extenuating and mitigating circumstances:
Comments
Comments:
Approval Signatures
Worker Signature: Supervisor Signature: ________________________________________________ _______________________________________________
Data Entry Worker Signature: Data Entry Date