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Has the facility owner, applicant, or director ever had a license denied, revoked or suspended in any state or jurisdiction or has been the

subject of a disciplinary action or had been fined while operating a child care facility or family day care home or employed in a child care

___

Yes

facility?

If Yes, please explain: ____________________________________________________________________________________

______________________________________________________________________________________________________

[Attach additional sheet(s) if necessary]

______________________________________________________________________________________________________________________

It is agreed that the undersigned has received a copy of Chapter 77-620, Special Acts, Laws of Florida, as amended, the Palm Beach County Rules

and Regulations Governing Child Care Facilities and other applicable regulations adopted by reference therein, and will adhere to the provisions of

these Laws, Rules and Regulations.

Pursuant to the Palm Beach County Rules and Regulations Governing Child Care Facilities, child enrichment service providers shall be of good

moral character based upon screening using Level 2 standards in Chapter 435, F.S. If this facility utilizes a child enrichment service provider, it is

the responsibility of the director to ensure that the child enrichment service provider is screened accordingly and parents/guardians provide written

consent before a child may participate in activities conducted by the child enrichment service provider. Your signature on this application indicates

your understanding and compliance with the law.

Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), personally identifiable health information must be protected from

disclosure and maintained in a manner to prevent inadvertent disclosure to the public and to otherwise assure the privacy of such information. Your

signature on this application indicates that you agree to comply with the requirements of HIPAA by protecting the confidentiality of employee and

children’s health records in your possession.

Falsification of application information is grounds for denial or revocation of the license to operate a child care facility. Under

penalty of perjury I hereby attest that the information contained in this application is truthful and correct.

This application may be withdrawn at any time the applicant so desires.

(________________________________________ DATE___________

(______________________________________ DATE__________

Signature of Owner or Designated Representative

Signature of Credentialed Director

____________________________________________

Print Name

____________________________________________

Title or Position in Facility

INFORMATION IN THIS BOX TO BE COMPLETED BY DEPARTMENT OF HEALTH STAFF ONLY

Facility Name:________________________________________________________

FOR OFFICE USE ONLY

Offender Search

Facility Address:______________________________________________________

Date: _____________

By: ____________________

Owner Name:________________________________________________________

Result: Exact match, Yes or No

Owner Real Property:__________________________________________________

Total Capacity: ________

Capacity of Children over Age 2 Years: ____________________

Infant Capacity: _______

PBCHD Representative: ________________________________

Page 2 of 2

Revised 8/2015

Application To Operate A Child Care Facility Form - Palm Beach County Child Care Facilities Board Page 2

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