Form Cc-200-A - Certified Family Child Care Provider Application Page 2
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2CC-200-A-FF (8-17)
Page 2 of 2
APPLICANT’S NAME:
ADULT AND MINOR CHILDREN OUT-OF-HOME
(Include spouse’s children and stepchildren)
Child #1
I and my significant other DO NOT have any adult or minor children who reside out-of-home
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
RELATIONSHIP TO YOU
(mm/dd/yyyy)
08/08/2017
Child #2
N/A
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
RELATIONSHIP TO YOU
(mm/dd/yyyy)
Child #3
N/A
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
RELATIONSHIP TO YOU
(mm/dd/yyyy)
Child #4
N/A
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
RELATIONSHIP TO YOU
(mm/dd/yyyy)
Child #5
N/A
LAST NAME
FIRST NAME
MIDDLE NAME
OTHER NAMES USED
(Maiden Name, other Married Names, Nicknames, etc.)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
RELATIONSHIP TO YOU
(mm/dd/yyyy)
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in
admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability,
genetics and retaliation. To request this document in alternative format or for further information about this policy, call
602-542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Disponible
en español en línea o en la oficina local.
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