Form OCC675 "Request for Continuing Large Family Child Care Home Registration" - Maryland

What Is Form OCC675?

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

Form Details:

  • Released on March 1, 2015;
  • The latest edition provided by the Maryland State Department of Education;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form OCC675 by clicking the link below or browse more documents and templates provided by the Maryland State Department of Education.

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Download Form OCC675 "Request for Continuing Large Family Child Care Home Registration" - Maryland

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MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
REQUEST FOR CONTINUING LARGE FAMILY CHILD CARE HOME REGISTRATION
FACILITY:
___________________
REGISTRATION #:_________________
The above named large family child care home registration is due to expire on __________________ ____
Please check your preference below and mail back to:
Licensing Specialist _______________________________________ Phone __________________________
Address: _________________________________________________________________________________
Email: ___________________________________________________________________________________
I will not continue to provide child care beyond the expiration date of my large family child care
registration. I will voluntarily close my large family child care home by the above noted expiration date.
Signature ____________________________________________________ Date _______________________
I desire to continue to provide child care beyond the expiration date of my large family child care
home registration and hereby submit the required documentation for conversion of my current
registration to continuing (non-expiring) status. I agree to continue to abide by the requirements of
COMAR 13A.18.01-.16. I understand that reporting false information may be grounds for denial or
revocation of my family child care registration.
Signature ____________________________________________________ Date _______________________
On the backside of this form, complete the section related to Worker’s Compensation Insurance
Information and Homeowners’ Liability Insurance Coverage, if applicable. Also, if any person(s) reside
on the facility's premises, please provide the specified information about those person(s).
OCC 675 – March 2015
Page 1 of 2
MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
REQUEST FOR CONTINUING LARGE FAMILY CHILD CARE HOME REGISTRATION
FACILITY:
___________________
REGISTRATION #:_________________
The above named large family child care home registration is due to expire on __________________ ____
Please check your preference below and mail back to:
Licensing Specialist _______________________________________ Phone __________________________
Address: _________________________________________________________________________________
Email: ___________________________________________________________________________________
I will not continue to provide child care beyond the expiration date of my large family child care
registration. I will voluntarily close my large family child care home by the above noted expiration date.
Signature ____________________________________________________ Date _______________________
I desire to continue to provide child care beyond the expiration date of my large family child care
home registration and hereby submit the required documentation for conversion of my current
registration to continuing (non-expiring) status. I agree to continue to abide by the requirements of
COMAR 13A.18.01-.16. I understand that reporting false information may be grounds for denial or
revocation of my family child care registration.
Signature ____________________________________________________ Date _______________________
On the backside of this form, complete the section related to Worker’s Compensation Insurance
Information and Homeowners’ Liability Insurance Coverage, if applicable. Also, if any person(s) reside
on the facility's premises, please provide the specified information about those person(s).
OCC 675 – March 2015
Page 1 of 2
WORKERS' COMPENSATION INSURANCE INFORMATION
Pursuant to the Maryland Workers' Compensation Act (Title 9 of the Labor and Employment Article, Annotated Code of
Maryland), the applicant must have worker’s compensation insurance coverage if the facility has one or more employees.
Please provide the following information about that coverage:
Name of Insurance Company: ________________________________________________________________
Insurance Policy/Binder Number: _____________________________________________________________
Effective Date of Coverage: _______________________
Expiration Date: ___________________________
HOMEOWNERS’ LIABILITY INSURANCE COVERAGE
Complete this section only if your large family child care home is located in a condominium or other residence that
requires homeowners’ association membership (NOTE: the Homeowners' Liability Insurance policy must be applicable to
child care):
Name of Insurance Company: _______________________________________________________________________
Insurance Policy/Binder Number: _____________________________________________________________________
Effective Date of Coverage: __________________________
Expiration Date: _______________________________
CURRENT HOUSEHOLD RESIDENTS
List all the children and adults living at the home.
FULL NAME
BIRTHDATE
RELATIONSHIP
RACE
MARITAL
SOCIAL SECURITY #
STATUS
OCC 675 – March 2015
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