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Oregon Department of Education • Early Learning Division • Office of Child Care • www.oregonearlylearning.com LIC-381 12/13/2018
Alternative Water Source Declaration
Facility Name: __________________________________________________________________
Name of Facility license holder: ____________________________________________________
This declaration verifies the facility named above does not use any of the on-site plumbing fixtures to obtain
water for drinking, cooking, preparing infant formula, or preparing food.
Alternate Water Source: ______________________________________________
The Office of Child Care encourages facilities to have a plan to ensure they always have a sufficient alternative
water source available for children and encourage testing of at least one faucet as a backup plan if the
alternative water source runs out.
Facility is required to notify the Office of Child Care in writing if the alternative source of water changes.
___________________________________ ___________________ Signature of license holder Date
___________________________________ Print name of license holder