Form OCC1275 "Additional Adult Application" - Maryland

What Is Form OCC1275?

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 October 1, 2008;
  • 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 OCC1275 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 OCC1275 "Additional Adult Application" - Maryland

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MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
ADDITIONAL ADULT APPLICATION
APPLICATION FOR APPROVAL OF THREE OR FOUR INFANTS/TODDLERS
1. Applying as an Additional Adult for:
Name of Registered Family Child Care Provider: __________________________________________
Address of Registered Home: _________________________________________ Apt. #: __________
City/Town: ____________________________ Zip Code: __________ Phone #: _________________
2. Name: ___________________________________________________________________________
Last
First
Middle
Maiden
If you have had any other names, please list them: _________________________________________
Female
Male
Social Security #: _______________________ Date of Birth: _____________
3. Home Address: ___________________________________________________ Apt. #: ___________
City/Town: ___________________________________ State: ___________ Zip Code: ___________
Phone #: ____________________________
E-mail address: _______________________________
Mailing Address (if different from home address): _________________________________________
_________________________________________________________________________________
4. If currently working, can you receive calls at work?
Yes
No
If Yes, give your work telephone number: _______________________________________________
5. Have you ever been convicted of any criminal charge, or are you awaiting trial on any criminal
charge?
Yes
No If Yes, explain: ______________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Page 1 of 2
OCC 1275 – Revised 10/08 – All previous editions are obsolete.
MARYLAND STATE DEPARTMENT OF EDUCATION
Office of Child Care
ADDITIONAL ADULT APPLICATION
APPLICATION FOR APPROVAL OF THREE OR FOUR INFANTS/TODDLERS
1. Applying as an Additional Adult for:
Name of Registered Family Child Care Provider: __________________________________________
Address of Registered Home: _________________________________________ Apt. #: __________
City/Town: ____________________________ Zip Code: __________ Phone #: _________________
2. Name: ___________________________________________________________________________
Last
First
Middle
Maiden
If you have had any other names, please list them: _________________________________________
Female
Male
Social Security #: _______________________ Date of Birth: _____________
3. Home Address: ___________________________________________________ Apt. #: ___________
City/Town: ___________________________________ State: ___________ Zip Code: ___________
Phone #: ____________________________
E-mail address: _______________________________
Mailing Address (if different from home address): _________________________________________
_________________________________________________________________________________
4. If currently working, can you receive calls at work?
Yes
No
If Yes, give your work telephone number: _______________________________________________
5. Have you ever been convicted of any criminal charge, or are you awaiting trial on any criminal
charge?
Yes
No If Yes, explain: ______________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Page 1 of 2
OCC 1275 – Revised 10/08 – All previous editions are obsolete.
6. Have you ever been reported for child or adult abuse or neglect?
Yes
No
If Yes, explain: _____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
7. Are you currently or have you ever been licensed, registered, or certified to provide child care in any
other county or state?
Yes
No
If Yes, give name of county and state and dates of license
or registration: ______________________________________________________________________
__________________________________________________________________________________
8. 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: ________
__________________________________________________________________________________
__________________________________________________________________________________
APPLICANT’S STATEMENT
I understand that I must submit all documents required by the Office of Child Care (OCC) to the
OCC Regional Office before my application can be approved.
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 Family Child Care Regulations (COMAR 13A.15.01-.15). If my application to
serve as an Additional Adult is approved, I agree to abide by those regulations, which include
(but are not limited to) the following requirements.
a. To cooperate in any investigation regarding my application;
b. To report all suspected cases of child abuse and neglect to the appropriate authorities;
c. To maintain records required by the regulations;
d. To permit unannounced visits by the Office of Child Care;
e. To supervise all children in care as required by Family Child Care Regulations.
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
Page 2 of 2
OCC 1275 – Revised 10/08 – All previous editions are obsolete.
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