Voluntary Certification Program (Vcp) Variance/waiver Application Form printable pdf download

(VCP) V

OLUNTARY

ERTIFICATION

ROGRAM

ARIANCE

AIVER

PPLICATION

Name of Child

Care Facility________________________________________________________ Address ______________________________________________________

City ____________________________________________________

County _______________________________ Zip______________________

I am applying for a variance of Child Care VCP Standard : ______________________________________________________________

(please identify and compete the exact standard/number)

which states _____________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

I am applying for a waiver of Child Care VCP Standard : _________________________________________________________________________

(please identify and compete the exact standard/number)

which states _____________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Variance Request

I am unable to comply with the above Child Care VCP Standard; therefore, I am requesting approval of the following alternative method of compliance which

will not be adverse to the health, safety or welfare of any child receiving services (attach additional pages as needed):

________________________________________________________________________________________________________________________________________________

Waiver Request

I am unable to comply with the above Child Care VCP standard and to comply with the specified rule will create an undue hardship for the following reason(s)

(attach additional pages as needed):

________________________________________________________________________________________________________________________________________________

If the wavier is approved, I will be in substantial compliance with the Child Care Standard because (attach additional pages as needed):

________________________________________________________________________________________________________________________________________________

Approval of this waiver will not be adverse to the health, safety or welfare of any child receiving services because (attach additional pages as needed):

________________________________________________________________________________________________________________________________________________

Facility Director or

Owner’s Signature _________________________________________________________________________

Date ___________________________

Printed Name of

Facility Director or Owner __________________________________________________________________________________________________________

Position with Child Care Facility _____________________________________________________________________________________________________

Incomplete applications will be returned to sender and processing delayed until a complete application is submitted to the FSSA/DFC/BCD at 402 West

Washington Street Room W386, Indianapolis, IN 46204.

FSSA/DFC USE ONLY

Registration #_______________________

Tracking Variance/Waiver #________________________