Form CCL.356 "Application for Review of Program Director Qualifications for School Age Programs" - Kansas

What Is Form CCL.356?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

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.356 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.356 "Application for Review of Program Director Qualifications for School Age Programs" - Kansas

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Kansas Department of Health and Environment
CCL. 356
Bureau of Family Health
Rev. 8/2020
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
FOR SCHOOL AGE PROGRAMS
INSTRUCTIONS: Complete ALL information requested and return to the Kansas Department of Health and Environment at the
(copy issued to student is acceptable)
above address. ATTACH OFFICIAL COLLEGE TRANSCRIPT
, IF APPLICABLE. Any
attachments should clearly state your current 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 without review.
This form is to be used for review of Program Director Qualifications according to K.A.R. 28-4-587. If you are wanting a review of
qualifications for a Child Care Center, Preschool or Head Start Program according to K.A.R. 28-4-429, please use the “Application
for Review of Program Director Qualifications for Child Care Centers, Preschools and Head Start Programs”.
____ Yes ____ No
As required pursuant to K.A.R. 28-4-587(b)(1)(C), I have graduated High School or completed a GED.
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: Please print clearly or type.
First and Last Name of Applicant
Date of Birth (MM/DD/YYYY)
Home Address of Applicant
City
State
Zip Code +4
County
Mailing Address of Applicant if different
City
State
Zip Code +4
County
Phone Number
FAX Number
Email Address
(
)
(
)
Record of Education (Check One):
I am requesting review of my qualifications for a license capacity of 30 or fewer children/youth.
I have (check one):
_____ completed at least three months of job-related experience as indicated on page 2 of this application.
_____ previously been approved as a program director as specified in K.A.R. 28-4-429(b) or (c). (Attach copy of approval.)
Kansas Department of Health and Environment
CCL. 356
Bureau of Family Health
Rev. 8/2020
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
FOR SCHOOL AGE PROGRAMS
INSTRUCTIONS: Complete ALL information requested and return to the Kansas Department of Health and Environment at the
(copy issued to student is acceptable)
above address. ATTACH OFFICIAL COLLEGE TRANSCRIPT
, IF APPLICABLE. Any
attachments should clearly state your current 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 without review.
This form is to be used for review of Program Director Qualifications according to K.A.R. 28-4-587. If you are wanting a review of
qualifications for a Child Care Center, Preschool or Head Start Program according to K.A.R. 28-4-429, please use the “Application
for Review of Program Director Qualifications for Child Care Centers, Preschools and Head Start Programs”.
____ Yes ____ No
As required pursuant to K.A.R. 28-4-587(b)(1)(C), I have graduated High School or completed a GED.
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: Please print clearly or type.
First and Last Name of Applicant
Date of Birth (MM/DD/YYYY)
Home Address of Applicant
City
State
Zip Code +4
County
Mailing Address of Applicant if different
City
State
Zip Code +4
County
Phone Number
FAX Number
Email Address
(
)
(
)
Record of Education (Check One):
I am requesting review of my qualifications for a license capacity of 30 or fewer children/youth.
I have (check one):
_____ completed at least three months of job-related experience as indicated on page 2 of this application.
_____ previously been approved as a program director as specified in K.A.R. 28-4-429(b) or (c). (Attach copy of approval.)
I am requesting review of my qualification for a license capacity of 31 through 60 children/youth. I have (check one):
_____ completed a minimum of 15 academic credit hours. (Attach copy of transcripts.)
_____ completed at least six months of job-related experience as indicated on page 2 of this application.
_____ previously been approved as a program director as specified in K.A.R. 28-4-429(d) or (e). (Attach a copy of approval.)
I am requesting review of my qualifications for a license capacity of 61 through 120 children/youth and have (check one):
_____ completed a minimum of 60 academic credit hours. (Attach copy of transcripts.)
_____ completed at least 12 months of job-related experience as indicated on page 2 of this application.
_____ completed a combination of 30 academic credit hours (attach copy of transcripts) and at least six months of job-related
experience as indicated on page 2 of this application.
_____ previously been approved as a program director as specified in K.A.R. 28-4-429(e). (Attach a copy of approval.)
I am requesting review of my qualifications for a license capacity of 121 or more children/youth and have:
_____ a minimum of a four-year bachelor’s degree from an accredited college or university (attach copy of transcripts) and
job related experience as indicated on page 2 of this application.
Record of current and previous teaching experience working with children or youth. Please list most current first. (If more
than space allows, please attach additional pages.)
Complete Name of Program
Street Address
City
State
Title of Position Held
Beginning Date
Ending Date
Age of Children or Youth
(MM/DD/YYYY)
(MM/DD/YYYY)
you worked with:
Complete Name of Program
Street Address
City
State
Title of Position Held
Beginning Date
Ending Date
Age of Children or Youth
(MM/DD/YYYY)
(MM/DD/YYYY)
you worked with:
Complete Name of Program
Street Address
City
State
Title of Position Held
Beginning Date
Ending Date
Age of Children or Youth
(MM/DD/YYYY)
(MM/DD/YYYY)
you worked with:
I attest, under penalty of perjury, that the information on this form and all its attachments is true and correct.
Applicant’s Signature
Date Completed (MM/DD/YYYY)

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