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Additional Adult Application - Application For Approval Of Three Or Four Infants/toddlers - Office Of Child Care Maryland State Department Of Education Page 2

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6. Have you ever been reported for child or adult abuse or neglect?

Yes

If Yes, explain: _____________________________________________________________________

__________________________________________________________________________________

7. Are you currently or have you ever been licensed, registered, or certified to provide child care in any

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other county or state?

Yes

If Yes, give name of county and state and dates of license

or registration: ______________________________________________________________________

__________________________________________________________________________________

8. Have you ever had a license, registration or certification for any type of care denied, suspended, or

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revoked?

Yes

If Yes, document when, where, and give a brief explanation: ________

__________________________________________________________________________________

APPLICANT’S STATEMENT

I understand that I must submit all documents required by the Office of Child Care (OCC) to the

OCC Regional Office before my application can be approved.

I understand the regulations can be viewed and printed from the following website:

I have read the Family Child Care Regulations (COMAR 13A.15.01-.15). If my application to

serve as an Additional Adult is approved, I agree to abide by those regulations, which include

(but are not limited to) the following requirements.

a. To cooperate in any investigation regarding my application;

b. To report all suspected cases of child abuse and neglect to the appropriate authorities;

c. To maintain records required by the regulations;

d. To permit unannounced visits by the Office of Child Care;

e. To supervise all children in care as required by Family Child Care Regulations.

The information I have given on this entire application form and on all other required application

documents is true, correct, and complete to the best of my knowledge.

_________________________________________________

________________________________

Signature

Date

Page 2 of 2

OCC 1275 – Revised 10/08 – All previous editions are obsolete.

Additional Adult Application - Application For Approval Of Three Or Four Infants/toddlers - Office Of Child Care Maryland State Department Of Education Page 2

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