Application For A School Age Only Center License
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7INSTRUCTIONS
Application for a School Age Only Center 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 School Age Only Center: The name of your school age only center which will appear on your license.
3. Physical Address of School Age Only 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 School Age Only Center: The phone number with the area code for the school age
only 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 School Age Only Center: The email address of the school age only center, where
correspondence from the Department of Health and Human Services can be sent.
7. Name of School Age Only Center Director: The name of the individual who will responsible for the day to
day operation of the school age only center program including compliance with all regulations.
8. Requested Licensed Capacity: Refer to the School Age Only Center Regulations to determine the capacity
of your 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 School Age Only Center Regulations to
determine what age range of children you may serve.
10. Hours of Operation: The hours that school age only care will be provided. Any hours between 9:00 pm and
6:00 am are considered overnight care. Please refer to School Age Only 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 School Age Only Center be located in a Private Residence? When the Center will NOT be located
in the applicant’s residence check the NO box and proceed to page 2 of the application. When the 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→→→→→
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