Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 12
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17State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE APPLICATION
Parent/Guardian Name:
LEGAL CARE ARRANGEMENT
Check the appropriate type of provider. If licensed, complete Day Care Licensing Information.
CENTERS AND LICENSED PROVIDERS
DAY CARE LICENSING INFORMATION
(DO NOT enter a Foster Care License Number)
Licensed Day Care Center (760)*
License Number:
Day Care Center Exempt from Licensing (761)
License Capacity:
Day
Night
Licensed Day Care Home (762)*
License Expiration:
Licensed Group Day Care Home (763)*
Hours of Operation:
From
To
CARE BY A RELATIVE (LICENSE NOT REQUIRED)
CARE BY A NON-RELATIVE (LICENSE NOT REQUIRED)
In the Child Care Provider's Home (765)
In the Child Care Provider's Home (764)
In the Child's Home (767)
In the Child's Home (766)
My relationship to the child(ren):
Other:
English
Spanish
Polish
Chinese
Language:
NOT REQUIRED FOR LICENSED PROVIDERS
If care is being provided in the home of the provider, list all other people living in the provider's home
DATE OF
RELATIONSHIP
SOCIAL SECURITY
FIRST NAME
LAST NAME
BIRTH
TO PROVIDER
NUMBER
IL444-3455 (R-6-11)
Page 12 of 17
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