"Family Child Care Home Renewal License Application Form" - Delaware

This "Family Child Care Home Renewal License Application Form" is a part of the paperwork released by the Delaware Department of Services for Children, Youth and their Families specifically for Delaware residents.

The latest fillable version of the document was released on October 1, 2017 and can be downloaded through the link below or found through the department's forms library.

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Download "Family Child Care Home Renewal License Application Form" - Delaware

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S
D
TATE OF
ELAWARE
OFFICE USE ONLY
Please print
D
S
C
, Y
T
F
EPARTMENT OF
ERVICES FOR
HILDREN
OUTH AND
HEIR
AMILIES
O
C
C
L
(OCCL)
FFICE OF
HILD
ARE
ICENSING
all responses.
F
C
C
H
Licensing specialist:
________
AMILY
HILD
ARE
OME
Date received:
R
L
A
ENEWAL
ICENSE
PPLICATION
License number: _______ License expiration date: ____/____/____
SECTION A – Identification
Applicant name:
Date of birth:
Race:
Alias, maiden, or married names this person has used:
Location address:
(street)
(city)
(county)
(state)
(zip)
Applicant cell phone #:
Location phone #:
Email address:
Fax #:
Entity Information (optional)
The “entity” is the LLC or corporation that is responsible for and has authority over the operation of the facility. If there is an entity, the
applicant must still have responsibility for the facility, reside in the facility, provide the child care, and control the space. If there is no
entity, check “individual” and leave the rest of this section blank. For family homes, the entity is usually an individual or an LLC.
Individual
Corporation
Entity name:
Entity type:
Limited liability company (LLC)
Doing business as/facility name:
Entity address:
(street)
(city)
(state)
(zip)
1. If the entity is an LLC, provide on a separate page a name, address, and phone number for the managing member.
2. If the entity is a corporation, provide on a separate page a name, address, and phone number for each corporate officer.
SECTION B – Additional Information
Household member(s) (other than the applicant, anyone staying in the home for more than 30 days within a year)
Full name
Alias, maiden, or married names this person has used
Date of birth
Race
Gender
Substitute(s)
Full name
Alias, maiden, or married names this person has used
Date of birth
Race
Gender
Revised 10/2017
Page 1 of 3
S
D
TATE OF
ELAWARE
OFFICE USE ONLY
Please print
D
S
C
, Y
T
F
EPARTMENT OF
ERVICES FOR
HILDREN
OUTH AND
HEIR
AMILIES
O
C
C
L
(OCCL)
FFICE OF
HILD
ARE
ICENSING
all responses.
F
C
C
H
Licensing specialist:
________
AMILY
HILD
ARE
OME
Date received:
R
L
A
ENEWAL
ICENSE
PPLICATION
License number: _______ License expiration date: ____/____/____
SECTION A – Identification
Applicant name:
Date of birth:
Race:
Alias, maiden, or married names this person has used:
Location address:
(street)
(city)
(county)
(state)
(zip)
Applicant cell phone #:
Location phone #:
Email address:
Fax #:
Entity Information (optional)
The “entity” is the LLC or corporation that is responsible for and has authority over the operation of the facility. If there is an entity, the
applicant must still have responsibility for the facility, reside in the facility, provide the child care, and control the space. If there is no
entity, check “individual” and leave the rest of this section blank. For family homes, the entity is usually an individual or an LLC.
Individual
Corporation
Entity name:
Entity type:
Limited liability company (LLC)
Doing business as/facility name:
Entity address:
(street)
(city)
(state)
(zip)
1. If the entity is an LLC, provide on a separate page a name, address, and phone number for the managing member.
2. If the entity is a corporation, provide on a separate page a name, address, and phone number for each corporate officer.
SECTION B – Additional Information
Household member(s) (other than the applicant, anyone staying in the home for more than 30 days within a year)
Full name
Alias, maiden, or married names this person has used
Date of birth
Race
Gender
Substitute(s)
Full name
Alias, maiden, or married names this person has used
Date of birth
Race
Gender
Revised 10/2017
Page 1 of 3
SECTION B – Additional Information, continued
CHU contact
Please provide a contact person and email to receive the fingerprinted background check results from the Criminal History
Unit (CHU). The results will contain confidential information about each person’s eligibility for employment or to reside at
a licensed child care facility.
CHU contact name:
Email:
SECTION C – Current Enrollment
Child’s name (FIRST NAME ONLY)
Date of birth
Days attending
Hours attending each day
Example:
Dante
5/22/10
M - F
8:00 a.m. - 5:00 p.m.
SECTION D – Program Information
Do you anticipate a change in the location or type of care provided in the next 12 months?
Yes
No
If “yes,” what is the anticipated change?
Hours of operation
Days of operation
Months of operation
_____ a.m. – _____ p.m. or a.m. (circle one)
M
T
W
Th
F
Sa
Su
January to December
August to June
Ages of children accepted
_______ to _______
(Use “kindergarten” for 5-year-olds attending kindergarten. Otherwise, use exact ages.)
Example: From 6 weeks to 12 years
From ___________________ to ___________________
Program components
Purchase of Care
Transportation:
field trips
daily
other
Food program (CACFP) agency:
Other (specify):
Revised 10/2017
Page 2 of 3
SECTION E – Certification and Signature
I have read, understand, and will follow DELACARE: Regulations for Family and Large Family Child Care Homes.
I understand that the Department of Services for Children, Youth and Their Families, Office of Child Care Licensing, is
required under Delaware law to make a thorough investigation to determine the good character and intention of the
applicant or applicants, that the individual home or facility meets the physical, social, moral, mental and educational
needs of the average child, whether the regulations and requirements of OCCL are properly met, and that the required
criminal background checks are completed and approved. That may consist of announced or unannounced on-site
review of the program and contacting of references submitted as well as other persons or agencies that may have
information pertinent to making the determination that the applicant has met the requirements for licensing.
I certify that to the best of my knowledge the applicant, substitutes, and household members do not have any conviction,
current indictment, or arrest involving violence against a person; child abuse or neglect; possession, sale, or distribution
of illegal drugs; sexual misconduct; or gross irresponsibility or disregard for the safety of others. I further certify if I
have knowledge of any convictions, indictments, or arrests involving any of the persons cited above, I will promptly
notify OCCL.
I certify that I have notified OCCL of any applicant, substitute, or household member, if applicable, known to me to have
lost custody of their own child or any child placed in their care; been diagnosed or under treatment for any serious
mental illness; or a current or former addiction to drugs or alcohol.
I agree that identifying information, including my name, address, and contact information, license status, enforcement
action, non-compliances, and substantiated complaints will be made available to the public through a variety of means,
including via the OCCL website.
I agree to comply with all federal, state, and local laws and regulations.
I certify that to the best of my knowledge all information I have given to OCCL is true and correct. I will continue to
supply true and correct information. Submitting false information or failing to provide complete information when
requested may result in warning of probation, probation, suspension, revocation of the license, or denial of a license
application.
_______________________________________________________________
__________________________________________________
Signature of applicant from page 1
Date
STATE OF DELAWARE
)
: SS
COUNTY OF ___________
)
Signed and attested before me this ____________________________________________________.
____________________________________________________________
__________________________________________________
Signature of notarial officer
Print name
(seal)
Revised 10/2017
Page 3 of 3
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