Form CCL.307 "Application for Review of Program Director Qualifications" - Kansas

What Is Form CCL.307?

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 August 1, 2020;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL.307 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.307 "Application for Review of Program Director Qualifications" - Kansas

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Kansas Department of Health and Environment
CCL.307
Rev. 08/2020
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
Website:
www.kdheks.gov/kidsnet
APPLICATION FOR REVIEW OF PROGRAM DIRECTOR QUALIFICATIONS
Instructions: Complete ALL information requested and return to the Kansas Department of Health and Environment.
ATTACH OFFICIAL COLLEGE TRANSCRIPT (copy issued to student is acceptable), and any supporting documentation to
meet the qualifications under K.A.R. 28-4-429 in the Kansas Laws and Regulations for Licensing Preschools and Child Care
Centers regulation book. Each attachment should clearly document applicant’s first and last name. Allow a minimum of 30
days for review. A Notice of Program Director Qualifications will be sent to the applicant. Incomplete applications will be
returned. PLEASE PRINT CLEARLY OR TYPE.
*
Refer to CCL 307a for additional instructions/information.
PLEASE CHECK ONE OF THE FOLLOWING:
______
I am requesting a first-time review of my education/experience for Program Director qualifications.
______
My education and experience have been previously reviewed by KDHE. Attached is a copy of the current
status of the last review. The information below is additional education and/or experience. I am requesting a
review to update my Program Director qualifications.
APPLICANT INFORMATION:
____________________________________________________________________________________
First Name
Last Name
Date of Birth
____________________________________________________________________________________
Home Street Address
City
State
Zip Code
Mailing Address (if different from home address):
____________________________________________________________________________________
Street Address
City
State
Zip Code
______________________________________
____________________________________
County
Phone Number
______________________________________
Email Address
PLEASE CHECK ONE OF THE FOLLOWING:
______
I am not currently employed as a Program Director.
______
I am currently employed or am being considered for hire as a Program Director for the following facility:
_____________________________________________________________________________________________
Name of the child care facility (as stated on the license)
License Number
_____________________________________________________________________________________________
Street Address
City
Zip Code
Kansas Department of Health and Environment
CCL.307
Rev. 08/2020
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
Website:
www.kdheks.gov/kidsnet
APPLICATION FOR REVIEW OF PROGRAM DIRECTOR QUALIFICATIONS
Instructions: Complete ALL information requested and return to the Kansas Department of Health and Environment.
ATTACH OFFICIAL COLLEGE TRANSCRIPT (copy issued to student is acceptable), and any supporting documentation to
meet the qualifications under K.A.R. 28-4-429 in the Kansas Laws and Regulations for Licensing Preschools and Child Care
Centers regulation book. Each attachment should clearly document applicant’s first and last name. Allow a minimum of 30
days for review. A Notice of Program Director Qualifications will be sent to the applicant. Incomplete applications will be
returned. PLEASE PRINT CLEARLY OR TYPE.
*
Refer to CCL 307a for additional instructions/information.
PLEASE CHECK ONE OF THE FOLLOWING:
______
I am requesting a first-time review of my education/experience for Program Director qualifications.
______
My education and experience have been previously reviewed by KDHE. Attached is a copy of the current
status of the last review. The information below is additional education and/or experience. I am requesting a
review to update my Program Director qualifications.
APPLICANT INFORMATION:
____________________________________________________________________________________
First Name
Last Name
Date of Birth
____________________________________________________________________________________
Home Street Address
City
State
Zip Code
Mailing Address (if different from home address):
____________________________________________________________________________________
Street Address
City
State
Zip Code
______________________________________
____________________________________
County
Phone Number
______________________________________
Email Address
PLEASE CHECK ONE OF THE FOLLOWING:
______
I am not currently employed as a Program Director.
______
I am currently employed or am being considered for hire as a Program Director for the following facility:
_____________________________________________________________________________________________
Name of the child care facility (as stated on the license)
License Number
_____________________________________________________________________________________________
Street Address
City
Zip Code
RECORD OF CURRENT AND PREVIOUS TEACHING EXPERIENCE working with children in a licensed child care facility:
(Please list most current first and attach additional pages if necessary)
Note: Out of state experience to be considered for approval requires a letter from the licensed facility verifying employment.
The letter must include all information requested below. Out of state experience must be from a regulated facility.
1._________________________________________________________________________________________________
Name and Address of licensed of licensed facility
Street
City
State
Title of Position
_____________________________________________________________________________________________________________
Beginning Date (MM/YY)
Ending Date (MM/YY)
Age of Children worked with
Employee, Volunteer or Student
2._________________________________________________________________________________________________
Name and Address of licensed of licensed facility
Street
City
State
Title of Position
_____________________________________________________________________________________________________________
Beginning Date (MM/YY)
Ending Date (MM/YY)
Age of Children worked with
Employee, Volunteer or Student
3.
______________________________________________________________________________________________________
Name and Address of licensed of licensed facility
Street
City
State
Title of Position
_____________________________________________________________________________________________________________
Beginning Date (MM/YY)
Ending Date (MM/YY)
Age of Children worked with
Employee, Volunteer or Student
RECORD of EDUCATION:
Yes ______
No ________
I have graduated High School or completed a GED.
Yes ______
No ________
I have completed a Child Development Association (CDA) Credential. I have
attached a copy of my CDA Credential.
Yes ______
No ________
I have completed Credit Hours or a Degree at an accredited Post-Secondary
Institution. I have attached a copy of my OFFICIAL transcripts.
Type of Degree: ___________ Major: ___________________________
Record of Observations:
Yes ______ No________
I have completed observations. I have attached a copy of the completed KDHE
Record of Observations form (CCL 207).
The information completed on this form and all its attachments is true and correct.
_______________________________________________
________________________________
Applicant’s Signature
Date MM/DD/YYYY

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