Form CFS672-5 "Licensing Exemption Request for School-Aged Child Care Programs for Non-child Care Assistance Funded Program (Ccap)" - Illinois

What Is Form CFS672-5?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Illinois Department of Children and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form CFS672-5 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form CFS672-5 "Licensing Exemption Request for School-Aged Child Care Programs for Non-child Care Assistance Funded Program (Ccap)" - Illinois

795 times
Rate (4.8 / 5) 40 votes
CFS 672-5
6/2017
State of Illinois
Department of Children and Family Services
Licensing Exemption Request for School-aged Child Care Programs
for Non-Child Care Assistance Funded Program (CCAP)
Complete this Affidavit if Your Exempt Program will NOT be serving Child Care
Assistance Program (CCAP) Funded Children.
Name of Program:
Sponsoring Agency or Institution:
Program Operational Dates:
Physical Address of Program:
Mailing Address (if different):
Telephone:
Please describe the funding source for this program :
TEEN Reach
Community Development Block Grant
Program (CDBG)
st
21
Century Community Learning Center
grant (CCLC)
Temporary Assistance for Needy Families
(TANF) funds
Child and Adult Care Food Program
(CACFP)
Workforce Development Grants
Child Care Assistance Program (CCAP)*
Other (please describe):
*Note: If your program receives CCAP or Child Care Development Fund (CCDF) funding you must
complete a CFS 672-6 License Exemption Request for School-aged Child Care Programs Seeking
Child Care Assistance Program (CCAP) Approval.
Reason for Submitting this Form (check one):
Change of Location (List previous address):
Request to Renew Exemption
New Exemption
Change in months, days or hours of operation; ages served; program name (Specify)
CFS 672-5
6/2017
State of Illinois
Department of Children and Family Services
Licensing Exemption Request for School-aged Child Care Programs
for Non-Child Care Assistance Funded Program (CCAP)
Complete this Affidavit if Your Exempt Program will NOT be serving Child Care
Assistance Program (CCAP) Funded Children.
Name of Program:
Sponsoring Agency or Institution:
Program Operational Dates:
Physical Address of Program:
Mailing Address (if different):
Telephone:
Please describe the funding source for this program :
TEEN Reach
Community Development Block Grant
Program (CDBG)
st
21
Century Community Learning Center
grant (CCLC)
Temporary Assistance for Needy Families
(TANF) funds
Child and Adult Care Food Program
(CACFP)
Workforce Development Grants
Child Care Assistance Program (CCAP)*
Other (please describe):
*Note: If your program receives CCAP or Child Care Development Fund (CCDF) funding you must
complete a CFS 672-6 License Exemption Request for School-aged Child Care Programs Seeking
Child Care Assistance Program (CCAP) Approval.
Reason for Submitting this Form (check one):
Change of Location (List previous address):
Request to Renew Exemption
New Exemption
Change in months, days or hours of operation; ages served; program name (Specify)
This request for exemption shall be accompanied by the following attachments:
A Notarized Statement that the facility complies with:
a. The Standards of the Illinois Department of Public Health or local health department
b. Fire Safety Standards of the Illinois State Fire Marshal
c. If operated in a public school building, the health and safety standards of the Illinois
State Board of Education.
A copy of the Employee/volunteer Emergency Preparedness manual or written procedures
and a copy of required drill logs.
A document that details where first aid kits are located in your facility, their minimum
contents, how they are inventoried and how staff are informed/trained on their availability,
location and contents and procedures for reporting refilling needs.
A copy of verification of minimum liability insurance coverage for your facility (at the
location listed above) of no less than $300,000 single limit per occurrence.
Information regarding the availability of a working telephone on site and accessible at all
times. If different than that above, provide the number. If not a landline, provide a
description of your facility’s plan to insure that the phone is in working order at all times.
Description of where emergency phone numbers are posted and which numbers are available.
Description of the locations of the Illinois State Police “No Firearms” sign posted at all
entrances and a copy of the policy or document that is provided to parents notifying them in
writing that firearms are prohibited on the premises.
A written statement that the facility engages and complies with the background check and
clearance requirements to obtain criminal history checks through the Illinois State Police,
FBI and checks of the Illinois Sex Offender Registry, and Child Abuse and Neglect Tracking
System for employees and volunteers who work directly with children.
A copy of the facility’s written procedure or policy which addresses a staff or volunteer who
does not receive a clearance following the IDHS background check.
A copy of the written notification to parents or guardians indicating the parent or guardian
has been advised and understands that the facility and program is not licensed or regulated by
DCFS.
A copy of the parent/guardian form which gathers information on each child enrolled, and
details on how and when the information is gathered and used and a description of how
records are maintained and disposed of in a manner that protects privacy and confidentiality.
At a minimum, the information on each child should include: first and last name of the child,
date of birth, name address and phone number of each parent, emergency contact
information, and written authorization for medical care.
A notarized statement that the facility complies with Illinois Department of Human Services
Rule 50.820 Staff Qualifications for License Exempt School-Age Providers that all staff
members have the appropriate level of professional and educational qualifications and
experience to work with school-age youth.
A notarized statement that the facility complies with Illinois Department of Human Services
Rule 50.830 Training Standards for License Exempt School-Age Providers which addresses
facility staff members’ initial orientation and annual trainings.
By completing this request you are requesting the Illinois Department of Children and Family Services to
determine compliance with the Illinois Child Care Act Section 2.09(a-j). You also understand and agree
that, upon request, verification of compliance with any or all of the requirements must be submitted.
By completing this request, you are certifying that your program provides care only for school-age
children (defined as “full time kindergartener or older”) during hours that school is not typically in
session—before/after school, school holidays, summer vacation, etc.) and that you are requesting the
Illinois Department of Children and Family Services to review the documents you have submitted as part
of this packet to determine compliance with the Illinois Child Care Act Section 2.09(j) in order to apply
for or maintain eligibility for Child Care Assistance Program (CCAP) through IDHS. You also agree
that if requested, you will submit additional documentation to further support compliance with any or all
of the requirements.
Program Manager/Operator/Director Signature
Date
INSTRUCTIONS for Programs not requesting CCAP exemption
Please submit to the Illinois Department of Children and Family Services Day Care Licensing
Office nearest the location of the facility. You will find a list of the DCFS Licensing Offices in your
information packet. Address the packet “Attention: Day Care Licensing Supervisor”
Upon verification of all required items, DCFS will forward a letter which confirms your compliance
with the exemption requirements and your status as an exempt facility. This letter is valid for two (2)
years.
If you plan to make change to your program or no longer meet any of the requirements as listed above,
you must contact the DCFS office issuing your exemption letter to discuss these proposed changes prior
to implementation. Changes in program such as, but not limited to include: change in physical location, a
change in operating months, days, and/or hours or a change in the ages served. Failure to notify the
DCFS office may result in a determination that your facility is no longer exempt.
If you have any questions, please phone the DCFS Licensing office nearest you and ask to speak with a
Day Care Licensing Supervisor.
Day Care Licensing Office Contact List
Northern Region
AURORA
630-801-3400
8 E GALENA BLVD, SUITE 300, AURORA
60506
DEKALB
815-787-5300
760 PEACE RD, DEKALB
60115
ELGIN
847-888-7620
595 S STATE ST, ELGIN
60123
FREEPORT
815-235-7878
1826 S WEST AVE, FREEPORT
61032
GLEN ELLYN
630-790-6800
800 ROOSEVELT RD, BLDG D-10, GLEN ELLYN 60137
JOLIET
815-730-4000
1619 W JEFFERSON, JOLIET
60435
KANKAKEE
815-939-8140
505 S SCHUYLER, KANKAKEE
60901
ROCKFORD
815-987-7640
200 S WYMAN ST, 2ND FL, ROCKFORD
61101
STERLING
815-625-7594
2607 WOODLAWN RD, SUITE 3, STERLING
61081
WAUKEGAN
847-249-7800
2133 BELVIDERE ROAD, WAUKEGAN
60085
WOODSTOCK
815-338-1068
113 NEWELL ST, WOODSTOCK 60098
Central Region
BLOOMINGTON
309-828-0022
401 BROWN ST, BLOOMINGTON
61701
CHAMPAIGN
217-278-5500
2125 S 1ST ST, CHAMPAIGN
61820
CHARLESTON
217-348-7661
825 18TH ST, CHARLESTON
61920
DANVILLE
217-443-3200
401 N FRANKLIN, DANVILLE
61832
DECATUR
217-875-6750
2900 N OAKLAND AVE, B, DECATUR
62526
GALESBURG
309-342-3154
467 E MAIN, GALESBURG
61401
JACKSONVILLE
217-479-4800
46 N CENTRAL PARK PLAZA, JACKSONVILLE
62650
LINCOLN
217-735-4402
405 N LIMIT ST, LINCOLN
62656
OTTAWA
815-433-4371
1580 FIRST AVE, OTTAWA
61350
SPRINGFIELD
217-782-4000
1124 N WALNUT, SPRINGFIELD
62702
PEORIA
309-693-5400
5415 N UNIVERSITY ST, PEORIA
61614
QUINCY
217-221-2525
107 N 3RD ST, QUINCY 62301
ROCK ISLAND
309-794-3500
500 42ND ST, SUITE 5, ROCK ISLAND
61201
Southern Region
BELLEVILLE
618-257-7500
1220 CENTREVILLE AVE, BELLEVILLE
62220
MARION
618-993-7100
2309 W MAIN, MARION
62959
MOUNT VERNON
618-244-8400
321A WITHERS DR, MOUNT VERNON
62864
Chicago City and Cook County
CHICAGO
312-808-5000
1911 S INDIANA, CHICAGO
60616
Page of 4