Application For A Family Child Care Home Ii License
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7INSTRUCTIONS
Application for a Family Child Care Home II 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 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: 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.
6. Email Address: The email address of the family child care, where correspondence from the Department of
Health and Human Services can be sent.
7. Name of Primary Provider: The name of the individual who will responsible for the day to day operation of
the Family Child Care Home II program including compliance with all regulations.
8. Requested License Capacity: Refer to the Family Child Care Home II 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.
9. Age Range of Children to be Served by Program: Refer to the Family Child Care Home II 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 Family Child Care Home II 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. You must provide the required information for ALL persons who are designated as primary provider, staff,
substitutes, volunteers, including YOURSELF.
15. Will the Family Child Care Home II be located in a Private Residence? When the Family Child Care Home
II will NOT be located in the applicant’s residence check the NO box and proceed to page 2 of the application.
When the Family Child Care Home II 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→→→→→
FCCH II
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