Application For Licensed Type B Home - Licking County Job And Family (Page 2 of 4) in pdf

Application For Licensed Type B Home - Licking County Job And Family Page 2

Hours Worked

Position

Day Working

Time of Work

Per Day

Sat

Are you currently receiving OWF benefits?

Are you a foster parent?

Yes

Are you a specialized care foster home?

Yes

Are you caring for foster children at this time?

If yes, please list their name and age

Yes

Name of foster care worker(s) and agency(ies)

Have you previously been certified or licensed or are you currently certified or licensed as a child care provider by the Ohio

Department of Job and Family Services (ODJFS) or any CDJFS?

Yes

If yes, please list

Do you have a swimming pool or open body of water 18 inches or deeper at your residence? If yes, it shall be inaccessible to

children.

Yes

Section III - Training and Experience

Have you had any formal training in child care?

Yes

If yes, complete this chart

Certificate, Diploma or

Year Completed

Name of Course

Credential Received

Summarize your previous experience in caring for children and/or in child care related employment and indicate the length of the

experience.

JFS 01643 (Rev. 1/2014)

Page 2 of 4

Application For Licensed Type B Home - Licking County Job And Family Page 2