Child Care Center Variance/waiver Application Form
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V
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A
HILD
ARE
ENTER
ARIANCE
AIVER
PPLICATION
Name of Child
Care Center________________________________________________________ Address ______________________________________________________
City ____________________________________________________
County _______________________________ Zip______________________
I am applying for a variance of Child Care License Rule 470 IAC 3-4.7 ______________________________________________________________
(please identify and compete the exact rule number)
which states _____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
OR
I am applying for a waiver of Child Care License Rule 470 IAC 3-4 _________________________________________________________________
(please identify and compete the exact rule number)
which states _____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Variance Request
I am unable to comply with the above Child Care Licensing Rule; 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 License Rule 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 Rules 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):
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Center Director or
Owner’s Signature _________________________________________________________________________
Date ___________________________
Printed Name of
Center Director or Owner __________________________________________________________________________________________________________
Position with Child Care Center _____________________________________________________________________________________________________
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
License #_______________________
Tracking Variance/Waiver #________________________
Recommendation Child Care Health Manager:
Recommendation Consultant:
□ Approved □ Denied
___________________________Signature
_____Date
□ Approved □ Denied
___________________________Signature
_____Date
Recommendation SFM:
Recommendation Licensing Manager:
□ Approved □ Denied
___________________________Signature
_____Date
□ Approved □ Denied
___________________________Signature
_____Date
(Comments may be on back page.)
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