Dfps Form J-800-2838 - Request For Exemption From Regulation Page 3

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J-800-2838
New June 2014
SECTION D - NEIGHBORHOOD RECREATION EXEMPTION
What is the age range of the children that you serve?
Does your program's governing body adopt standards for care that, at a minimum, include staffing ratios, staff
training, health and safety standards, and mechanisms for monitoring whether and how the program follows the
standards, enforces the standards, and receives and resolves complaints from the parents of enrolled children?
No
Yes
Do you accept compensation other than a nominal annual membership fee or solicit donations as payment for services
or goods provided as part of the program?
No
Yes
Is your program organized as a nonprofit organization or located at the participant's home?
No
Yes
Do you inform parents that the state does not license your program?
No
Yes
Do you advertise or represent your program as a child care facility, a day care center, a licensed before-school or
after-school program, or as offering child care services?
No
Yes
Does your program conduct background checks through the Department of Public Safety on all program employees
and volunteers who work with children?
No
Yes
SECTION E - CAREGIVER WITH WRITTEN AGREEMENT
Complete this section if you are requesting an exemption based on meeting the requirements for being a caregiver
who has a written agreement with a parent to provide residential care under 40 TAC §745.129(3).
Do you provide care to more than one child or sibling group unrelated to you?
No
Yes
Did you have a previous relationship with the child, the sibling group, or their family members?
No
Yes
Do you receive compensation or solicit donations for the care of the child or sibling group?
No
Yes
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