Application For A Family Child Care Home I License printable pdf download

INSTRUCTIONS

Application for a Family Child Care Home I License

PROGRAM INFORMATION

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

license.

2. Name of Family Child Care Program: The name of your program which will appear on your license.

3. Physical Address of Family Child Care Program: The physical address must be your residence.

4. Phone/Fax Number: The phone number with the area code for the family child care program. You are required

to have an operating phone on the premises. A cell phone is acceptable. A fax number is requested, if available.

5. Email Address: The email address of the family child care, where correspondence from the Department of

Health and Human Services can be sent.

6. Name of Primary Provider: The name of the individual who will responsible for the day to day operation of

the Family Child Care Home I program including compliance with all regulations.

7. Requested License Capacity: Refer to the Family Child Care Home I Regulations to determine the capacity

of your program. 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.

8. Age Range of Children to be Served by Program: Refer to the Family Child Care Home I Regulations to

determine what age range of children you may serve (The most common range is 6 weeks to 13 years).

9. 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 Family Child Care Home I Regulations regarding overnight care.

10. Days of Operation: Check each day of the week you will be operating your program.

11. 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.

12. 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.

13. You must 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.”

14. You must provide the required information for ALL persons who are designated as staff, substitutes, volunteers,

including YOURSELF.

Instructions continue on next page→→→→→

FCCH I

Application For A Family Child Care Home I License