Minnesota Department Of Human Services Application For Family Child Page 2
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24. Special family child care home information*
(employer, church, community collaborative, not-for-profit agency) Circle one. Please attach required
information. See instructions.
name (empLoyeR, ChuRCh, CommunITy CoLLaboRaTIve, noT-FoR-pRoFIT agenCy)
ConTaCT peRSon: pRInT CLeaRLy
STReeT addReSS
CITy
CounTy
STaTe
ZIp Code (9 dIgIT)
aRea Code and phone numbeR
5. License information*
7. Dwelling information
Type of residence:
License classification
License capacity________________________
l
l
l
Family child care
Child foster care
l
l
l
Single family
Apartment
Duplex/twin home
l
l
l
Foster family
A
Employer
l
l
l
Mobile home
Town house
Other
Foster residence
l
l
B1
Church
l
l
l
Own/rent:
Own
Rent
Treatment foster care
l
l
B2
Community collaborative
l
l
Non-residential:
Yes
No
l
l
l
C1
Not-for-profit agency
l
Attached garage:
Conditional
Yes
No
l
l
l
C2
l
l
Basement:
Conditional
Yes
No
l
No infants in care
C3
l
l
l
l
First floor
Conditional
Yes
No
l
No transporting children under 9
l
l
D
Second floor
Conditional
Yes
No
l
l
l
Type of client
Above second floor
Conditional
Yes
No
Adult foster care
Child foster care
l
l
note: Conditional means certain conditions apply to the usage of this area based
Developmentally disabled
Relatives only
l
l
upon minnesota Rules, the minnesota uniformed Fire Code and other applicable
Physically disabled
Relatives and non-relatives
building requirements
l
l
Mentally ill
Non-relatives only
l
8. Sensitive mailing address for child foster care residence BGS*
Elderly
l
name (LaST, FIRST, mI)
Other
6. Dates* Fill in appropriate dates (month-day-year):
STReeT addReSS
*
Effective*
Expiration
______ _____ _____
______ _____ _____
agenCy CITy
STaTe
ZIp Code
BGS*
Fire inspection
______ _____ _____
______ _____ _____
If corporate foster care, name, date of birth, BGS date and study ID number of
the highest ranking official:
Name ________________________________________________________
DOB ___________ BGS date ____________ DHS Study ID ___________
9. Signature*
I have completed the necessary reviews and hereby recommend that the applicant be licensed pursuant to the laws and rules of the state of
Minnesota. The provider’s signed application, and authorized representative information, is maintained in the agency file.
SIgnaTuRe oF auThoRIZed agenCy RepReSenTaTIve
daTe
LICenSoR name (pRInT)
agenCy and LICenSoR Code
CounTy oR pRIvaTe agenCy
aRea Code and TeLephone numbeR
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