Application for a Child Care Center License
1. Type of License: Indicate whether you are applying for a Provisional License (first year of licensure) or are
applying for a Non-Expiring Operating License (you must have first completed one year under a provisional
2. Name of Child Care Center: The name of your child care center which will appear on your license.
3. Physical Address of Child Care Center: The physical address where the program is operated
4. Type of Structure: Indicate whether the program is located in a church, school or other structure such as a
store front, government building, etc.
5. Phone/Fax Number of Child Care Center: The phone number with the area code for the child care center.
You are required to have an operating phone on the premises. A cell phone is acceptable. A fax number is
requested, if available.
6. Email Address of Child Care Center: The email address of the child care center, where correspondence from
the Department of Health and Human Services can be sent.
7. Name of Child Care Center Director: The name of the individual who will responsible for the day to day
operation of the child care center program including compliance with all regulations.
8. Requested Licensed Capacity: Refer to the Child Care Center Regulations to determine the capacity of your
child care center. The capacity you request may not be approved by DHHS and/or the Fire Marshal. The
number of children in care cannot exceed the licensed capacity at any time.
9. Age Range of Children to be Served by Program: Refer to the Child Care Center Regulations to determine
what age range of children you may serve (The most common range is 6 weeks to 13 years).
10. Hours of Operation: The hours that child care will be provided. Any hours between 9:00 pm and 6:00 am are
considered overnight care. Please refer to Child Care Center Regulations regarding overnight care.
11. Days of Operation: Check each day of the week you will be operating your program.
12. Preferred Mailing Address: The address where all mail from the Department of Health and Human Services
should be sent. Include Street, P.O. Box (if applicable), city, state, & zip code.
13. Child Care Subsidy: Indicate whether you: Accept child care subsidy; Currently do not accept subsidy, but
willing to in the future; or Do not accept subsidy.
14. Will the Child Care Center be located in a Private Residence? When the Child Care Center will NOT be
located in the applicant’s residence check the NO box and proceed to page 2 of the application. When the Child
Care Center WILL be located in the applicant’s residence check the YES box. You must then provide the
required information for ALL persons residing in the household.
NOTE: Applicant must submit zoning
approval from relevant jurisdiction, to the Department of Health and Human Services to meet licensing
requirements--- Refer to document “Additional Documentation Required.”
Instructions continue on next page→→→→→