J-800-2838
New June 2014
SECTION B - PROGRAM INFORMATION
What ages do you serve?
How many children participate in your program?
What are your program's operating hours?
Name the specific days of the week that your business operates:
Describe the program that you are requesting an exemption for:
SECTION C - REQUIRED DOCUMENTS
Indicate below the documentation that you are submitting with your exemption request. Submitting the
documentation with your request helps DFPS process your request efficiently and effectively.
Description of all services provided
Description of how each service provided is directly related to the program.
Copies of information given to parents about the program (including enrollment forms, policies, schedules, and
parent guides).
Daily schedule that describes what children do from the time that they arrive until they leave. (If your program
offers services during school breaks, include the schedule for those days too.)
Weekly or monthly schedule
Fees collected for the services provided
Floor plan (including rest rooms, areas used by the children, and areas used by other programs that operate at
the same time)
Informational and advertising materials (including Internet pages and links)
Other information that demonstrates that your program is exempt
SECTION D - NEIGHBORHOOD RECREATION EXEMPTION
Complete this section if you are requesting an exemption based on meeting the requirements for being a
neighborhood recreation program under 40 TAC §745.129(1).
Does your program provide activities designed for recreational purposes?
No
Yes
If yes, describe the types of activities:
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