Form CCL.309 "Inquiry Regarding Licensure Child Care Center, Preschool or Mother's Day out" - Kansas

What Is Form CCL.309?

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 March 1, 2017;
  • 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.309 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

ADVERTISEMENT
ADVERTISEMENT

Download Form CCL.309 "Inquiry Regarding Licensure Child Care Center, Preschool or Mother's Day out" - Kansas

857 times
Rate (4.6 / 5) 51 votes
CCL.309
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
(785) 296-1270 Fax (785) 559-4244
Website: www.kdhe.gov/kidsnet
INQUIRY REGARDING LICENSURE
CHILD CARE CENTER, PRESCHOOL OR MOTHER’S DAY OUT
Good beginnings last a lifetime. The service you offer to children and youth is important to the community and will have a lasting
impact on the children and youth in your program. Kansas child care laws and regulations are designed to reduce the predictable
risk of harm to children and youth. By completing and submitting this application you are:
(CHECK ONE)
______ 1) requesting determination of required licensure; OR
______ 2) notifying KDHE that a child care facility or preschool that does not require licensure exists.
Submit the completed and signed inquiry to the Kansas Department of Health and Environment at the above address.
Allow a minimum of 30 days for a written determination of licensure.
=============================================================================
SECTION I: FACILITY INFORMATION. COMPLETE ALL INFORMATION REQUESTED. PLEASE PRINT.
Official Name of the Child Care Center, Preschool or Mother’s Day Out Facility
Physical Address of Program: Street Address
City
Zip Code
County
Phone Number
Fax Number
Email Address
(
)
(
)
Mailing Address of the Program: Street Address
City
Zip Code
===================================================================================================
SECTION II:
LEGAL OWNER/OPERATOR INFORMATION. COMPLETE ALL INFORMATION REQUESTED. PLEASE
PRINT.
Name of the Legal Owner/Operator
Physical Address of the Owner/Operator: Street Address
City
Zip Code
County
Phone Number
Fax Number
Email Address
(
)
(
)
Mailing Address of the Owner/Operator: Street Address
City
Zip Code
CCL.309
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
(785) 296-1270 Fax (785) 559-4244
Website: www.kdhe.gov/kidsnet
INQUIRY REGARDING LICENSURE
CHILD CARE CENTER, PRESCHOOL OR MOTHER’S DAY OUT
Good beginnings last a lifetime. The service you offer to children and youth is important to the community and will have a lasting
impact on the children and youth in your program. Kansas child care laws and regulations are designed to reduce the predictable
risk of harm to children and youth. By completing and submitting this application you are:
(CHECK ONE)
______ 1) requesting determination of required licensure; OR
______ 2) notifying KDHE that a child care facility or preschool that does not require licensure exists.
Submit the completed and signed inquiry to the Kansas Department of Health and Environment at the above address.
Allow a minimum of 30 days for a written determination of licensure.
=============================================================================
SECTION I: FACILITY INFORMATION. COMPLETE ALL INFORMATION REQUESTED. PLEASE PRINT.
Official Name of the Child Care Center, Preschool or Mother’s Day Out Facility
Physical Address of Program: Street Address
City
Zip Code
County
Phone Number
Fax Number
Email Address
(
)
(
)
Mailing Address of the Program: Street Address
City
Zip Code
===================================================================================================
SECTION II:
LEGAL OWNER/OPERATOR INFORMATION. COMPLETE ALL INFORMATION REQUESTED. PLEASE
PRINT.
Name of the Legal Owner/Operator
Physical Address of the Owner/Operator: Street Address
City
Zip Code
County
Phone Number
Fax Number
Email Address
(
)
(
)
Mailing Address of the Owner/Operator: Street Address
City
Zip Code
The Legal Owner/Operator is a (check ONE of the following):
_______
individual, partnership or association of individuals that is (are) not incorporated
_______
corporation
_______
government agency other than a local unit of government or public school district
_______
local unit of government or public school district
_______
nonpublic school that is
_______ accredited by ______________________________________________________________________
_______ nonaccredited
_______
other (please describe) ______________________________________________________________________
===================================================================================================
CHILD CARE CENTER, PRESCHOOL, OR MOTHER’S DAY OUT HOURS OF OPERATION. COMPLETE ALL
SECTION III:
INFORMATION REQUESTED. PLEASE PRINT.
Indicate the months of the year, hours and days of the week you will be providing services to children and youth (check only one
option for each schedule you complete):
_____ All Year (Jan through Dec)
_____ Summer Only (June through Aug)
_____ School Year Only (Sept through May)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
____ All Year (Jan through Dec)
_____ Summer Only (June through Aug)
_____ School Year Only (Sept through May)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
The child care center, preschool or mother’s day out operates more than five consecutive hours
_____ Yes _____ No
OR more than one day per week.
_____ Yes _____ No
The parents of the children in the program are on the premises and immediately accessible to
attend to their children (i.e. attending to voluntary activities such as physical exercise and not
enrolled in course work or engaged in employed work).
SECTION IV:
CHILDREN/YOUTH SERVED BY THE PROGRAM.
_____ Yes _____ No
The program serves infants. Infant means a child who is between two weeks and 12 months of age,
or a child over 12 months who has not learned to walk pursuant to K.A.R. 28-4-420(k).
_____ Yes _____ No
The program serves toddlers. Toddler means a child who has learned to walk and who is
between 12 and 30 months of age pursuant to K.A.R. 28-4-420(dd).
_____ Yes _____ No
The program serves preschool age children. Preschool age means a child who is between 30
months of age and the age of eligibility to enter kindergarten as prescribed in K.S.A. 72-1107(c) and any
amendments thereto pursuant to K.A.R. 28-4-420(u).
_____ Yes _____ No
The program serves kindergarten and school age children. Kindergarten age means eligibility to
enter kindergarten as prescribed in K.S.A. 72-1107(c) and any amendments thereto. School age children
means a child who will attain the age of six years on or before the first day of September of any school
year, but who is not 16 years of age pursuant to K.A.R. 28-4-420(x).
SECTION V:
TO BE COMPLETED FOR PRESCHOOL PROGRAMS THAT ARE OPERATED BY INDIVIDUALS,
PARTNERSHIPS OR AN ASSOCIATION OF INDIVIDUALS; CORPORATIONS OR GOVERNMENT AGENCIES
OTHER THAN PUBLIC SCHOOL DISTRICTS (all other owners skip to the next section).
_____ Yes _____ No
The program is conducted in sessions not exceeding three hours per session.
_____ Yes _____ No
The program does not enroll any child more than one session per day.
_____ Yes _____ No
The program does not serve a meal.
SECTION VI.
TO BE COMPLETED FOR PRESCHOOL PROGRAMS OWNED AND OPERATED BY NON-PUBLIC
SCHOOLS ONLY (all other owners skip to the next section).
_____ Yes _____ No
The preschool program is operated on the premises of a private school providing kindergarten
through grade six.
_____ Yes _____ No
The preschool program provides learning experiences for only children who are preschool age
pursuant to K.A.R. 28-4-420(t)(1).
_____ Yes _____ No
The preschool program does not exceed three hours per session.
_____ Yes _____ No
The preschool does not enroll any child more than one session per day.
_____ Yes _____ No
The preschool program does not serve a meal.
I attest, under penalty of perjury, that to the best of my knowledge, the information in this section is true and correct.
______________________________________________________________________________
__________________
Signature of School Authority (Principal, Attorney for School, Governing Body President)
Date Signed
SECTION VII.
TO BE COMPLETED FOR PRESCHOOL AND HEAD START PROGRAMS OWNED AND OPERATED BY
PUBLIC SCHOOL DISTRICTS OR INTERLOCALS ONLY (all other owners skip to the next section).
_____ Yes _____ No
The program is a preschool program for children age 3 to kindergarten age.
_____ Yes _____ No
The program is operated pursuant to K.S.A. 72-67,115.
_____ Yes _____ No
The program is operated by the Board of Education or operated through an interlocal agreement.
_____ Yes _____ No
The Board of Education contracts with public or private entities, that are not Board of Education,
to operate the preschool program.
I attest, under penalty of perjury, that to the best of my knowledge, the information in this section is true and correct.
________________________________________________________________________________
__________________
Signature of School Authority (Principal, Superintendent, Attorney for District, School Board President)
Date Signed
SECTION VIII.
OTHER THAN A PRESCHOOL - DESCRIPTION OF THE PROGRAM
_____ Yes _____ No
The program is a Head Start program that is not owned and operated by a school district.
_____ Yes _____ No
The program operates more than three hours and children attend less than 24 hours per day.
_____ Yes _____ No
The program serves kindergarten and school age children and youth only and requests
determination pursuant to the regulations governing a child care centers rather than as a school
age or drop in program. If requesting determination pursuant to the school age or drop in program
regulations, please use form CCL.360.
SECTION IX. Provide a brief overview of the goals and purpose of the program (attach additional sheet for information, if
needed).
SECTION X. AGREEMENTS AND AUTHORIZED SIGNATURE. READ EACH STATEMENT AND SIGN WHEN COMPLETED.
I/We the undersigned, am [are the person(s)] named as the Owner or the person(s) authorized to represent the owner listed above.
I/We understand that if a determination that a license is required, a new application must be submitted may take up to 90 days for
processing by the Kansas Department of Health and Environment (KDHE), once KDHE receives a complete application. I/We
understand that I/we are not authorized to provide services to children and youth prior to receiving a Temporary Permit or License
from KDHE. Determination is based on the information provided by the owner in this inquiry as of the date signed. If
changes to the program are made, a new inquiry regarding licensure should be submitted to the department.
I/We attest, under penalty of perjury, that to the best of my (our) knowledge, the information provided in this inquiry is true and
correct.
Authorized Signature:
Date (MM/DD/YYYY)
Page of 3