Application For A Child Care License Form printable pdf download

Application For A Child Care License Form

DCDEE 07/13

IVISION OF

HILD

EVELOPMENT AND

ARLY

DUCATION

DCDEE U

NLY

A C

PPLICATION

HILD

ARE

ICENSE

ID#

_____________________________________________________________

OUNTY

– F

PPLICATION

ACILITY

ROFILE

______ OF ______

AGE

Profile Page Instructions:



Complete this form neatly in ink



Be sure to sign and date the form



Incomplete or incorrectly completed forms will be returned to you

1. Owner Name: ___________________________________________________________________________________

2. Facility Name:

______

3. Facility Mailing Address:

/PO B

TREET

ITY

TATE

ODE

Land Line/Published Unpublished Cellular Phone

4. Facility Phone Number: (

)

5. Location Address:

TREET

ITY

ODE

OUNTY

6. Ownership Type:  Individual Owner

 Corporate Owner  Government

7. Facility Contact Person

(if different from applicant)

Date of Birth (if applicable)____________________

Phone Number: (_____) ______-___________

Email Address: _____________________________

Cell Phone Number: (_____) _____-________

Fax Number: (_____) _____-________

8. Requested Age Range:

9. Hours of Operation:

Days of Operation:

 Full Day

 Part Day

 School-age Only

Preschool Only

10. Types of care to be provided:

 First Shift  Second Shift

 Third Shift

Preschool and School-age

 New Construction

 Purchasing Existing Child Care Operation

Type of Building

 Renovating Building for Child Care

 Other_____________________

 Family Child Care Home

 Drop-in

 Center in a Residence

12. Type of Facility

 Center

 Religious Sponsored (GS-110)

 Summer Day Camp

13. Proposed Opening Date: _____________________________ Did you attend a Prelicensing Workshop? Yes No

If yes, please list the Prelicensing Workshop Date_____________ City _______________ County______________

If no, select reason:  Pending

Current Owner  DPI

 Location Change

14. Proposed Number of Children to Be Served: __________________________

Application For A Child Care License Form

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