Form CCL.801 "Application for a School Age Drop-In Program" - Kansas

What Is Form CCL.801?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on June 1, 2019;
  • The latest edition provided by the Kansas Department of Health & Environment;
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Download a printable version of Form CCL.801 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.801 "Application for a School Age Drop-In Program" - Kansas

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Kansas Department of Health and Environment
Rev. 6/2019
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone 785-296-1270 Fax: 785-559-4244
www.kdheks.gov/kidsnet
INSTRUCTIONS FOR COMPLETING THE APPLICATION
FOR A LICENSED SCHOOL AGE DROP-IN PROGRAM
NEW APPLICANTS:
This includes all facilities required to be licensed; currently licensed programs that are moving,
ownership changes, and programs changing from one category to another.
Applicants must complete ITEMS 1 THROUGH 8 BELOW. If you are applying for a NEW licensed
School Age Drop-In Program, return the required forms and fee to the Kansas Department of Health and
Environment (KDHE) at the above address.
INTENT TO CONTINUE: COMPLETE THE FORMS LISTED UNDER 1, 3, 4, and 5 BELOW. If you are renewing your
(ANNUAL RENEWAL)
current license, return the required forms and the annual licensing fee to KDHE at the above address.
CLOSURE:
If you are no longer operating your School Age Drop-In Program, you must notify KDHE of your closure.
Complete Sections I (Notification of Closure), II and VI of the application and send it along with your
license to KDHE at the above address.
1.
INSTRUCTIONS FOR APPLICATION:
APPLICATION FOR LICENSE: Applications for a new license are to be submitted a minimum of 90 days prior to the
anticipated opening of the facility. Applications are processed in the order received. The facility is not authorized to
provide services to children or youth prior to receiving a temporary permit or license.
CLEARLY PRINT OR TYPE using black ink. Complete all statements carefully and include all requested information as
attachments. Please review the completed application prior to mailing to KDHE to be sure that all items listed on the
application are included and CAREFULLY CHECK the accuracy of the information you are submitting. Incomplete
applications may be returned.
TOTAL LICENSE CAPACITY OF THE FACILITY. Provide the requested capacity for the facility. Total capacity of a
facility will be determined by KDHE at the time of licensure. The maximum capacity of a facility is determined by program
director qualifications, available indoor and outdoor space for children, and fire approval.
SHOW FACILITY ADDRESS ON WEBSITE. Checking “yes” to this question authorizes KDHE to publish the facility
address and phone number on a compliance report made available to the public through the online compliance information
system.
2.
ORIENTATION:
If you currently have a license, you do not need to complete this section. If you are applying for a
new license, please complete the date of your orientation. If you have not attended an orientation session, please
contact the local child care facility surveyor.
3.
BACKGROUND AND REGISTRY CHECK FORMS - CCL 002 (revised 12/2018) and **CCL 002a DIP affiliate role list
(revised 5/2019):
Complete the Background and Registry Checks for Child Care Facilities form CCL 002 that was revised 12/2018.
CLEARLY PRINT OR TYPE all information requested.
**Effective 12/1/2018 - Form CCL 002a DIP must be used to determine appropriate role for each affiliate.
Effective June 7, 2018, requirements for background checks changed (K.A.R. 28-4-125). For certain individual(s)
working, residing or volunteering in a facility a fingerprint-based background check and fee may be required. For additional
information regarding the background check process and fee(s), visit www.kdheks.gov/kidsnet.
EVERY INDIVIDUAL WORKING, RESIDING, OR VOLUNTEERING IN A FACILITY MUST HAVE A COMPLETED
BACKGROUND AND REGISTRY CHECK. This includes yourself, any individual at least 10 years of age residing in the
facility, any individual working or volunteering in the facility and any individual whose activities involve supervised or
unsupervised access to children. DO NOT INCLUDE children enrolled for child care. New individual(s) must be submitted
for a background and registry checks and results received prior to being permitted to work, reside, or volunteer in a facility.
KDHE will notify the applicant/licensee when fingerprint-based background check(s) are required and when results are
received.
1
Kansas Department of Health and Environment
Rev. 6/2019
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone 785-296-1270 Fax: 785-559-4244
www.kdheks.gov/kidsnet
INSTRUCTIONS FOR COMPLETING THE APPLICATION
FOR A LICENSED SCHOOL AGE DROP-IN PROGRAM
NEW APPLICANTS:
This includes all facilities required to be licensed; currently licensed programs that are moving,
ownership changes, and programs changing from one category to another.
Applicants must complete ITEMS 1 THROUGH 8 BELOW. If you are applying for a NEW licensed
School Age Drop-In Program, return the required forms and fee to the Kansas Department of Health and
Environment (KDHE) at the above address.
INTENT TO CONTINUE: COMPLETE THE FORMS LISTED UNDER 1, 3, 4, and 5 BELOW. If you are renewing your
(ANNUAL RENEWAL)
current license, return the required forms and the annual licensing fee to KDHE at the above address.
CLOSURE:
If you are no longer operating your School Age Drop-In Program, you must notify KDHE of your closure.
Complete Sections I (Notification of Closure), II and VI of the application and send it along with your
license to KDHE at the above address.
1.
INSTRUCTIONS FOR APPLICATION:
APPLICATION FOR LICENSE: Applications for a new license are to be submitted a minimum of 90 days prior to the
anticipated opening of the facility. Applications are processed in the order received. The facility is not authorized to
provide services to children or youth prior to receiving a temporary permit or license.
CLEARLY PRINT OR TYPE using black ink. Complete all statements carefully and include all requested information as
attachments. Please review the completed application prior to mailing to KDHE to be sure that all items listed on the
application are included and CAREFULLY CHECK the accuracy of the information you are submitting. Incomplete
applications may be returned.
TOTAL LICENSE CAPACITY OF THE FACILITY. Provide the requested capacity for the facility. Total capacity of a
facility will be determined by KDHE at the time of licensure. The maximum capacity of a facility is determined by program
director qualifications, available indoor and outdoor space for children, and fire approval.
SHOW FACILITY ADDRESS ON WEBSITE. Checking “yes” to this question authorizes KDHE to publish the facility
address and phone number on a compliance report made available to the public through the online compliance information
system.
2.
ORIENTATION:
If you currently have a license, you do not need to complete this section. If you are applying for a
new license, please complete the date of your orientation. If you have not attended an orientation session, please
contact the local child care facility surveyor.
3.
BACKGROUND AND REGISTRY CHECK FORMS - CCL 002 (revised 12/2018) and **CCL 002a DIP affiliate role list
(revised 5/2019):
Complete the Background and Registry Checks for Child Care Facilities form CCL 002 that was revised 12/2018.
CLEARLY PRINT OR TYPE all information requested.
**Effective 12/1/2018 - Form CCL 002a DIP must be used to determine appropriate role for each affiliate.
Effective June 7, 2018, requirements for background checks changed (K.A.R. 28-4-125). For certain individual(s)
working, residing or volunteering in a facility a fingerprint-based background check and fee may be required. For additional
information regarding the background check process and fee(s), visit www.kdheks.gov/kidsnet.
EVERY INDIVIDUAL WORKING, RESIDING, OR VOLUNTEERING IN A FACILITY MUST HAVE A COMPLETED
BACKGROUND AND REGISTRY CHECK. This includes yourself, any individual at least 10 years of age residing in the
facility, any individual working or volunteering in the facility and any individual whose activities involve supervised or
unsupervised access to children. DO NOT INCLUDE children enrolled for child care. New individual(s) must be submitted
for a background and registry checks and results received prior to being permitted to work, reside, or volunteer in a facility.
KDHE will notify the applicant/licensee when fingerprint-based background check(s) are required and when results are
received.
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4.
FIRE SAFETY:
NEW APPLICANTS: Contact the Kansas State Fire Marshal’s Office and obtain a fire safety acceptance. Acceptance
must be submitted with the application. A temporary permit or license will not be issued until fire acceptance is submitted.
To obtain the General Rules or forms as well as obtain requirements for new programs, please contact the Kansas State
Fire Marshal’s Office one of the following ways:
ONLINE: Visit the website at www.kansas.gov/firemarshal.
TELEPHONE: If you do not have access to a computer, call the Kansas State Fire Marshal’s Office at 785-296-3401.
Request that instructions and forms for a Child Care Center or Preschool be mailed to you.
INTENT TO CONTINUE/ANNUAL RENEWAL: The School Age Drop-In Program must comply with all applicable rules
and regulations of the Kansas State Fire Marshal. An annual fire safety inspection will be conducted. A copy of the fire
safety inspection is to be available for review by the local child care licensing surveyor. If the School Age Drop-In Program
is located in a public school or public recreation facility, the current fire safety inspection for the facility is accepted as the
current fire safety inspection for the school age program. If you have questions about the fire safety inspection, contact the
State Fire Marshal at 785-296-3401.
5.
FEES:
A. LICENSE FEE:
The license fee amount is $20.00, which must accompany the application. If payment is made by debit or credit card,
complete information as required on the application. If payment is made by check, cashier’s check or money order make
payable to KDHE. The license fee is not refundable.
B. LOCAL FEE:
KDHE contracts with local health departments or private contractors to provide local regulatory services. Private
contractors may charge a local fee. Please contact your local child care licensing surveyor to determine the amount of any
local fee(s) and submit that fee directly to the local health department or private contractor per their instructions.
APPLICANTS FOR A NEW LICENSE MUST ALSO COMPLETE
AND SUBMIT THE FOLLOWING INFORMATION.
6.
VERIFICATION OF THE LEGAL OWNER OR OPERATOR.
Private Owner or Partnership that is not Incorporated.
Submit a copy of the lease or deed for the property and, pursuant to K.S.A. 1991 Supp. 74-139, a copy of the
Social Security Card, Driver’s License or Birth Certificate for each owner or partner. If located in a church, school,
or other building not owned by the individual or partnership, include authorization signed by the owner of the
property granting permission for the operation of the program on their premises.
Corporate and LLC Owners.
Submit the Federal Identification Number and the Kansas Secretary of State’s Business Entity ID Number. If located
in a church, school, or other building not owned by the corporation, include authorization signed by the owner of the
property granting permission for operation of the program on their premises.
Governmental Agency including School District.
Submit the Federal Identification Number assigned to the legal owner. If located in a church, school, or other
building not owned by the government agency, include authorization signed by the owner of the property granting
permission for the operation of the program on their premises.
7.
PROGRAM INFORMATION.
Description of Program Activities and Services to be provided including a statement of the program’s
purpose and goals including description of services provided such as educational and recreational activities,
transportation, etc., the number and ages of children and youth for whom the program is designed, anticipated
opening date.
Program Director pursuant to K.A.R. 28-4-701(d). Submit a KDHE Program Director Approval letter if
available. If not available, complete and return the enclosed Program Director's Application included in this
packet.
8.
SANITARIAN’S APPROVAL:
If connected to private water or sewage disposal system a sanitarian’s approval is necessary to verify compliance
as required by K.S.A. 65-508(a).
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** ADDITIONAL INFORMATION **
KDHE ANNUAL KDHE INSPECTION:
K.S.A. 65-512 requires that all licensed facilities be inspected at least once every twelve months. An initial,
scheduled inspection will be requested by KDHE when a complete application is received and the facility is ready for
occupancy. Your local child care licensing surveyor will make an ANNOUNCED initial inspection of the facility and the
surrounding outdoor area. All future inspections including compliance checks, complaint investigations and annual reviews
are UNANNOUNCED. The annual inspection will not necessarily occur at the time of your annual renewal date. KDHE
provides dates for inspection to the local child care licensing surveyor. Inspection dates may change from year to year. If
you have questions or comments about your inspection, please contact KDHE at 785-296-1270.
KDHE CHILD CARE FORMS:
Current KDHE forms are enclosed for your use. Please make copies of these forms for future program use. Destroy
all unused copies of out-of-date forms, if you have any. Forms are also available for download at the KDHE website
www.kdheks.gov/kidsnet.
REGULATORY QUESTIONS:
The local child care licensing surveyor is your first and primary contact for questions about your child care
facility, child care laws and regulations. Surveyors have a supply of Law and Regulation books. To request a regulation
book, contact your local surveyor or download the laws and regulations from the KDHE website at
www.kdheks.gov/kidsnet. Surveyors are also a good source of information about other local services including educational
opportunities that may be available to child care facility owners and staff.
OTHER INFORMATION:
Once you have obtained a temporary permit or license, you may be eligible for services provided by other agencies.
Child Care Reimbursement for families receiving assistance with child care. For more information about contracting
with the Department for Children and Families (DCF) to receive child care payments from families receiving assistance
with child care, please contact DCF at 1-888-369-4777. The local child care licensing surveyor or child care resource and
referral agency can provide you with the contact information for your area.
Child and Adult Care Food Program. You may be eligible for partial reimbursement for providing nutritious meals and
snacks to children in your care. Contact the food program sponsor serving your area. The local child care licensing
surveyor or child care resource and referral agency can provide you with the contact information for a sponsor in your area.
Child Care Resource and Referral Agencies are available to assist you with training and referral services. For more
information, contact the local child care resource and referral agency or Child Care Aware at 1-877-678-2548 or
www.ks.childcareaware.org.
Good Beginnings Last A Lifetime!
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