Form OCC1230 "Application for Family Child Care Registration" - Maryland

What Is Form OCC1230?

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 July 1, 2014;
  • The latest edition provided by the Maryland State Department of Education;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form OCC1230 by clicking the link below or browse more documents and templates provided by the Maryland State Department of Education.

ADVERTISEMENT
ADVERTISEMENT

Download Form OCC1230 "Application for Family Child Care Registration" - Maryland

Download PDF

Fill PDF online

Rate (4.6 / 5) 7 votes
MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
APPLICATION FOR FAMILY CHILD CARE REGISTRATION
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ SECTION I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(To Be Completed By Regional Office)
st
OCC Region#:______ Jurisdiction: ______________ CCATS Provider ID#: ________________
1
Orientation Date: _______________
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SECTION II _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(To Be Completed By Applicant)
I am applying as a : (check one)
First Registration
Co-Provider Applicant With: ____________________________________________
Provider’s Name
Applicant
____________________________________________
Provider’s Address
1.
Applicant’s Name: ___________________________________________________________________________________________________
Last
First
Middle
Maiden
If you have had any other names, please list: ______________________________________________________________________________
Social Security #: _________________________________________
Tax ID # (If applicable): __________________________________
2.
Personal Identifying Data (NEEDED FOR CLEARANCE)
(a)
Race (check all that apply):
American Indian or Alaskan Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White
Other (specify): ___________________________
Ethnicity:
Hispanic or Latino
Non-Hispanic or Latino
(b) Marital Status:
Single
Married
Widowed
Separated
Divorced
(c) Primary Spoken Language: __________________________ (d) Date of Birth: ______________
(e) Sex:
Male
Female
(f) E-mail address: ____________________________________________________________________________________________________
Applicant’s Residence: _______________________________________________________________________ County: _________________
3.
City: _____________________________________
State: ________________
Zip Code: ______________ Apartment #.: ____________
Development (If applicable): _________________________________________
Residence Telephone #: (________)___________________
Status:
Homeowner
Renter
Other
Year Property Built ____________
Lead Risk Reduction Certificate
Lead Free Certificate
If OTHER, please explain: ______________________________________________________________________________________________
4.
If currently working, can you receive calls at work?
YES
NO
If YES, give your work telephone number: _________________________________________________________________________________
IF APPLYING AS CO-PROVIDER STOP HERE AND PROCEED TO SECTIONS III AND IV
OCC 1230 - Revised 7/14 - All previous editions are obsolete.
Page 1 of 4
MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care
APPLICATION FOR FAMILY CHILD CARE REGISTRATION
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ SECTION I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(To Be Completed By Regional Office)
st
OCC Region#:______ Jurisdiction: ______________ CCATS Provider ID#: ________________
1
Orientation Date: _______________
__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SECTION II _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(To Be Completed By Applicant)
I am applying as a : (check one)
First Registration
Co-Provider Applicant With: ____________________________________________
Provider’s Name
Applicant
____________________________________________
Provider’s Address
1.
Applicant’s Name: ___________________________________________________________________________________________________
Last
First
Middle
Maiden
If you have had any other names, please list: ______________________________________________________________________________
Social Security #: _________________________________________
Tax ID # (If applicable): __________________________________
2.
Personal Identifying Data (NEEDED FOR CLEARANCE)
(a)
Race (check all that apply):
American Indian or Alaskan Native
Asian
Black or African-American
Native Hawaiian or Pacific Islander
White
Other (specify): ___________________________
Ethnicity:
Hispanic or Latino
Non-Hispanic or Latino
(b) Marital Status:
Single
Married
Widowed
Separated
Divorced
(c) Primary Spoken Language: __________________________ (d) Date of Birth: ______________
(e) Sex:
Male
Female
(f) E-mail address: ____________________________________________________________________________________________________
Applicant’s Residence: _______________________________________________________________________ County: _________________
3.
City: _____________________________________
State: ________________
Zip Code: ______________ Apartment #.: ____________
Development (If applicable): _________________________________________
Residence Telephone #: (________)___________________
Status:
Homeowner
Renter
Other
Year Property Built ____________
Lead Risk Reduction Certificate
Lead Free Certificate
If OTHER, please explain: ______________________________________________________________________________________________
4.
If currently working, can you receive calls at work?
YES
NO
If YES, give your work telephone number: _________________________________________________________________________________
IF APPLYING AS CO-PROVIDER STOP HERE AND PROCEED TO SECTIONS III AND IV
OCC 1230 - Revised 7/14 - All previous editions are obsolete.
Page 1 of 4
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SECTION II
)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(Continued
Will the child care home be located in a condominium or residence which requires Homeowner’s Association membership?
5.
YES
NO
(NOTE: If YES, please be advised that the home will need to be covered by Homeowner’s Liability Insurance applicable to day care, pursuant to
Maryland law. After you become registered, you will be required to submit documentation of that insurance to the OCC Regional Office.)
Type of Water Supply:
Private
Public
Type of Sewage Disposal:
Private
Public
6.
:
List the names of children (under 18 years of age) living in your residence
FULL NAME
SS #
BIRTHDATE
RELATIONSHIP
RACE
7.
List the full name of all adults (18 years of age or older) living in your residence:
MARITAL
FULL NAME
SS #
BIRTHDATE
RELATIONSHIP
RACE
STATUS
Is any adult living in your residence an employee of the Maryland State Department of Education (MSDE)?
YES
NO
8.
Are you a child/adult foster care provider?
YES
NO
Are you currently applying to become a foster care provider?
YES
NO
If YES, complete the information below:
AGENCY
CONTACT PERSON
TELEPHONE NUMBER
OCC 1230 - Revised 7/14 - All previous editions are obsolete.
Page 2 of 4
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _SECTION II
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(Continued)
9.
Have you or any other persons living in your residence ever been convicted of any criminal charge, or received a probation before
judgment disposition, or received a not criminally responsible disposition?
YES
NO
If YES, explain: ________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
10. Are you or any other persons living in your residence awaiting trial on any criminal charge?
YES
NO
_______________________________________________________________________________________________
If YES, explain:
___________________________________________________________________________________________________________
11. Have you or any other persons living in your residence ever been reported for child or adult abuse or neglect?
YES
NO
: _______________________________________________________________________________________________
If YES, explain
___________________________________________________________________________________________________________
12. Have you ever been licensed, or have you applied to become licensed, registered or certified to provide child care in any other county, state, or
federal jurisdiction?
YES
NO
If YES, state when and where: __________________________________________
__________________________________________________________________________________________________________
13. Have you ever had a license, registration or certification for any type of care denied, suspended or revoked?
YES
NO
: ______________________________________________________________
If YES, document when, where, and give a brief explanation
__________________________________________________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _SECTION III _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _
TO BE COMPLETED BY CO-PROVIDER ONLY
1.
Have you ever been convicted or any criminal charge, or received a probation before judgment disposition, or received a not criminally
responsible disposition?
YES
NO
2.
Are you awaiting trial on any criminal charge?
YES
NO
3.
Have you ever been reported for child abuse or neglect?
YES
NO
4.
Have you ever been licensed, or have you applied to become licensed, registered or certified to provide child care in any other county, state, or
federal jurisdiction?
YES
NO
If YES, state when and where: _____________________________________________________________________________________________
5. Have you ever had a license, registration, or certification for any type of care denied, suspended or revoked?
YES
NO
If YES, document when, where, and give a brief explanation: _____________________________________________________________________
_________________________________________________________________________________________________________________________
If you answered “YES” to questions 1, 2, or 3, please explain. (add additional sheets if necessary): __________________________________________
_________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
OCC 1230 - Revised 7/14 - All previous editions are obsolete.
Page 3 of 4
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ SECTION IV _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(To Be Completed by Applicant)
APPLICANT’S STATEMENT
I understand the regulations can be viewed and printed from the following website:
http://www.marylandpublicschools.org/MSDE/divisions/child_care/licensing_branch/regulat
I have read the regulations for family child care registration, COMAR 13A.14.01. If I am registered, I agree to abide
by those regulations, which include (but are not limited to) the following requirements:
a.
Display the registration certificate in a conspicuous place;
b. Maintain my assigned capacity;
c.
Provide supervision to the children in care at all times as required by family child care regulations;
d. Report to the appropriate authorities all suspected cases of child abuse and neglect;
e.
Report to the Office of Child Care (OCC) all serious injuries and deaths involving children in my care;
f.
Post emergency information;
g.
Cooperate in any investigation regarding my application or registration;
h. Permit unannounced visits by the OCC;
i.
Maintain all records required by the regulations;
j.
Give the Consumer Education Pamphlet to each parent of a child enrolled in my care;
k. Execute a written agreement with each parent; and
l.
Report to the OCC all changes which might affect the status of the registration.
The OCC distributes a mailing list of family child care providers that includes provider’s name, full address, and
telephone number. Under State Government Article § 10-617H (5) (Public Information”):
“A custodian who sells lists of licenses shall omit from the lists the name of any licensee, on written request of the
licensee.”
Please check one of the following:
Please keep my name on both the referral list and the mailing list.
Please keep my name on the mailing list, but remove it from the referral list.
Please keep my name on the referral list, but remove it from the mailing list. *
Please remove my name from both the referral list and the mailing list. *
*NOTE the following:
(1) By removing your name from the mailing list, you may lose the opportunity to receive information concerning
continued training and other mailings related to child care.
(2) By removing your name from the referral list, you may lose the opportunity to have parents referred to your
program by the Office of Child Care and local Child Care Resource and Referral Centers.
I understand that I must submit all documents required by the OCC to the Regional Office before my application can
be approved. The information I have given on this entire application form and on all other required application
documents is true, correct, and complete to the best of my knowledge.
_________________________________________________________
__________________________________
Signature
Date
OCC 1230 - Revised 7/14 - All previous editions are obsolete.
Page 4 of 4
Page of 4