Form Lic-309 - Voluntary Withdrawal/closure/unauthorized Adult Form printable pdf download

Voluntary Withdrawal/Closure/Unauthorized Adult Form

(Please check the boxes that apply)

Voluntary Withdrawal or Closure

I voluntarily WITHDRAW my application for (check all that apply below):

I voluntarily CLOSE my (check all that apply below):

Central Background Registry Enrollment

Registered Family Child Care Home

School-Age Recorded Program

Certified Child Care Center

Certified Family Child Care Home

Preschool-Age Recorded Program

Effective Date:

Reason for Withdrawal/Closure:

______________

____________________________________

NOTE

: If withdrawing or closing during a pending legal action (eg suspension, revocation, or removal) against your Registry enrollment

or child care license, the Office of Child Care will withdraw/close the enrollment or license as “in lieu of legal action”.

Withdrawal/Removal of Adult listed on Application

I voluntarily withdraw/remove the following adult(s) from my child care license application

Please continue processing the individual’s application for enrollment so that they may be linked to my

facility upon enrollment in the Central Background Registry

_____________________

Name: ____________________________ Physical Address

Phone: ____________

(required):

_____________________

Name: ____________________________ Physical Address

Phone: ____________

(required):

•

By my signature below I agree that the above individual(s) will not move into my home, reside in my home on a temporary basis, visit the home on a

regular basis, substitute for or assist me, or have unsupervised contact with child care children unless I first receive confirmation from the Division that

the individual(s) have been enrolled in the Central Background Registry.

Unauthorized Adult in Licensed Child Care Home

I understand that any adult residing in a licensed child care home, visiting the home on a regular basis, or substituting or assisting for the

provider must be enrolled in the Office of Child Care’s Central Background Registry.

Registered Family child care home provider: OAR 414-205-0040(3) and (4)

Certified Family child care home provider: OAR 414-350-0090(4)(a) and (b)

In order to be in compliance with the rules, the following individual(s) will not live in my home and will not have contact with child care

children in the home until they are enrolled in the Central Background Registry.

______________________________________________

___________________________________________________

Name of person not enrolled in the Central Background Registry

Physical Address (required)

City

Zip

______________________________________________

___________________________________________________

Name of person not enrolled in the Central Background Registry

Physical Address (required)

City

Zip

Name

: ______________________________________ License or CBR No: ______________

(Provider, Facility, or Individual)

Address: ________________________________________________________________________________________

Signature: ______________________________________________________ Date: __________________________

Please return form to: Office of Child Care, 875 Union St NE Salem OR 97311

Phone No: 503-947-1400 or 1-800-556-6616

Fax No: 503-947-1428

OFFICE OF CHILD CARE USE ONLY

Data Entry:

Issue Number

Closure Date

Letter Sent

Conditions Placed (CO)

Sent to CO (if applicable):

White: OCC

LIC-309 5/27/2016

Oregon Department of Education • Early Learning Division • Office of Child Care •

Yellow: Individual

Form Lic-309 - Voluntary Withdrawal/closure/unauthorized Adult Form

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