Fillable Form Oel-Vpk 10 - Statewide Provider Application printable pdf download

State of Florida

Program Year:

VOLUNTARY PREKINDERGARTEN EDUCATION PROGRAM

New Application

No Change

STATEWIDE PROVIDER REGISTRATION APPLICATION

Updated Application & Date:

I. PRIVATE PROVIDER/ PUBLIC SCHOOL INFORMATION

Type or print in black or blue ink

1. Provider Name (as on DCF license or accreditation certificate):

2. Employer Identification Number (EIN

)

3. DCF Identification Number or Exemption Number

4. Address of VPK Site (number and street)

5. City

6. County

7. Zip Code

8. Daytime Phone Number

9. Fax Number

10. Email Address (VPK site)

11. Mailing Address (if different from VPK Site)

Same as VPK Site

12. City

13. State

14. Zip Code

15. Owner or School District Staff

16. Owner Corporate Name (if applicable)

17. Daytime Phone Number

NOTE – See the Privacy Act Statement concerning EINs and Social Security Numbers on page 1 of the instructions accompanying this application.

II. TYPE OF SETTING AND LICENSING INFORMATION

Submit written documentation of items 18-19 as applicable

18. Type of Setting (check one):

Licensed Private Provider:

Non-Licensed Private Provider (must be license-exempt & accredited):

Public School:

Child Care Facility

Faith-Based Child Care (exempt under s.402.316, F.S.)

Public School (licensed or district

Family Day Care Home

Faith-Based Private School (exempt under s. 402.3025, F.S., or

approved charter school)

Large Family Child Care Home

s.402.316, F.S.)

Public School (exempt from

Private School

Nonreligious Private School (exempt under s. 402.3025, F.S.)

licensure under s. 402.3025, F.S.)

19. Specialized Program Type (if applicable):

20. District and School Number (public school only)

21. Total Child Capacity

Head Start

Charter School

III. ACCREDITATION INFORMATION

Required for license exempt private providers. Voluntary for all other providers.

If the provider is accredited by an accrediting agency that is a member of one of the organizations listed below or in s. 1002.55(3)(b), F.S., submit

written documentation of the accreditation (e.g. accreditation certificate). If not accredited by a member agency of those listed below, submit a copy of

the official Gold Seal Quality Care Designation certificate issued by the Department of Children and Family Services.

22. Provider’s accrediting agency is a member of:

23. Name of Accrediting Agency

National Council for Private School Accreditation

Florida Association of Academic Nonpublic Schools

24. Certificate Expiration Date

Southern Association of Colleges and Schools

Other (see section 1002.55(3)(b), F.S.):_______________________________________

None of the above (Using Gold Seal Quality Care Designation)

IV. DIRECTOR OR PRINCIPAL INFORMATION

Private Providers: Submit written documentation of items 28 – 31.

25. Full Name

26. Daytime Phone Number

27. Email Address

28. Director Credential Type:

29. Credential Issue Date

VPK Director Credential

Child Care Facility Director Credential (if completed by December 31, 2006)

30. Director Credential Certificate Number

31. Credential Expiration Date

I have examined this application and, to the best of my knowledge and belief, the information provided is true and correct. If any of this information

changes, I understand that the provider must submit updated information to the coalition in writing within 14 days of the change. I also understand

that the provider is encouraged to submit updated information before a change is implemented as the provider may be out of compliance with the

requirements of the VPK Program if the changes are implemented before the coalition approves of the changes.

32. Signature of Authorized Representative

By Electronic Signature

33. Date

34. Print Name of Authorized Representative

35. Daytime Phone Number

OFFICIAL USE ONLY

Process Agent

Date

Process Manager