Home Child Care Facility Application Form - Fairfax County, Virginia printable pdf download

FAIRFAX COUNTY, VIRGINIA

CEPS Team

FAMILY SERVICES OFFICE FOR CHILDREN

DIVISION OF COMMUNITY EDUCATION AND PROVIDER SERVICES

12011 Government Center Parkway, Suite 800 Fairfax, VA 22035-1102

□

Phone 703-324-8100

Fax 703-653-1302 TTY (Virginia Relay) 711

Initial

HOME CHILD CARE FACILITY APPLICATION

□

(Please print or type)

Renewal

SECTION A

A non-refundable payment of $14.00 must accompany this application. Make Personal Check, Certified

Check or Money Order payable to Office for Children, (OFC). One check can be used for all fees. Include

yourself in Section A, C, and D.

Provider Name _________________________________

___________________________

____________________________

Last

First

Middle

Phone _________________________________

E-mail _________________________

Fax _____________________________

Home/Work

(Optional)

Address ________________________________

City __________________________ State ___________ Zip Code __________

Home Child Care Facility Address/Name (if different)___________________________ Daytime Phone ______________________

Address ________________________________

City __________________________ State ___________ Zip Code __________

What are proposed hours and days of operation?

Hours _________________________ Days ______________________________

Race (ethnicity) __________________________

Birth Date _____________________

Do you have a Fairfax County Child Care Permit?

Yes _____ No _____

Did you ever have a Fairfax County Child Care Permit? Yes _____ No _____

SECTION B-Complete all information listed below for all children 13 years and under living at home.

(Indicate N/A, if not applicable)

1.__________________________ _______________________

_______________

______

_____ _________

Last

First

Middle

Sex

Race

Birth Date

2.__________________________ _______________________

_______________

______

_____ _________

Last

First

Middle

Sex

Race

Birth Date

3.__________________________ _______________________

_______________

______

_____ _________

Last

First

Middle

Sex

Race

Birth Date

4.__________________________ _______________________

_______________

______

_____ _________

Last

First

Middle

Sex

Race

Birth Date

SECTION C-Request for Search of the Central Registry Release of Information Form

Complete all information listed below for all adults and children 14 years and older living at home, including

the applicant and all substitute care providers. (Indicate N/A, if not applicable)

1.__________________________ _______________________

_______________

______

_____ _________

Last

First

Middle

Sex

Race

Birth Date

2.__________________________ _______________________

_______________

______

_____ _________

Last

First

Middle

Sex

Race

Birth Date

3.__________________________ _______________________

_______________

______

_____ _________

Last

First

Middle

Sex

Race

Birth Date

4.__________________________ _______________________

_______________

______

_____ _________

Last

First

Middle

Sex

Race

Birth Date

I/we understand that this information is required by the Office for Children for all persons 14 years of age and older who are household

members, assistants or child care employees as a condition of application and participation in OFC programs. I/we agree to notify OFC within

21 days whenever a current household member, not listed above, reaches the age of 14, and whenever any persons 14 years of age or older

move into the household. I/we understand that these persons will also need to consent to the terms of this agreement as a condition of

continuing participation in program(s) of OFC.

Home Child Care Facility Application Form - Fairfax County, Virginia

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