Form CCL.360 "Inquiry Regarding Licensure School Age or Drop-In Program" - Kansas

What Is Form CCL.360?

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;

Download a printable version of Form CCL.360 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

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Download Form CCL.360 "Inquiry Regarding Licensure School Age or Drop-In Program" - Kansas

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CCL.360
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
SCHOOL AGE OR DROP-IN PROGRAM
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 school age program 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 School Age or Drop-In Program
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.360
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
SCHOOL AGE OR DROP-IN PROGRAM
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 school age program 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 School Age or Drop-In Program
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) ______________________________________________________________________
===================================================================================================
SECTION III:
SCHOOL AGE OR DROP IN PROGRAM HOURS OF OPERATION. COMPLETE ALL 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
_____ Yes _____ No
The program is designed to allow two or more school children on a drop-in or enrolled basis to
attend 12 hours a week or more for more than two consecutive weeks.
SECTION IV:
CHILDREN/YOUTH SERVED BY THE PROGRAM.
_____ Yes _____ No
The program serves exclusively school age children and youth. School Age Child means an
individual who is of kindergarten age through the academic years in which the child is in the sixth grade
and who is attending the program. School Age Youth means an individual who has completed sixth
grade or is 12 years of age or older and is less than 18 years of age, is attending the program, and is not
a volunteer or employee.
_____ Yes _____ No
The program serves exclusively youth who are 16 years of age and older.
_____ Yes _____ No
The program is a Drop-In Program. K.A.R. 28-4-700(e) defines drop-in program as a child care facility
that is not located in an individual’s residence, that serves exclusively school-age children and youth, and
in which the operator permits children and youth to arrive at and depart from the program at their own
volition and at unscheduled times. This term shall not include a program, instructional, class, or activity
as specified in K.A.R. 28-4-578(b).
SECTION V:
TO BE COMPLETED FOR SCHOOL AGE AND DROP IN PROGRAMS OWNED AND OPERATED BY PUBLIC
SCHOOL DISTRICTS ONLY (all other owners skip to the next section).
_____ Yes _____ No
The program is an extraordinary school program pursuant to K.S.A. 72-8238.
_____ Yes _____ No
The program is a summer program pursuant to K.S.A. 72-8237.
_____ Yes _____ No
The program is operated for no more than 4 consecutive hours per day or for no more than 2
consecutive weeks pursuant to K.A.R 28-4-578(b)(6).
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 VI.
TO BE COMPLETED FOR SCHOOL AGE PROGRAMS OWNED AND OPERATED BY ACCREDITED
PRIVATE (NON-PUBLIC) SCHOOLS ONLY (all other owners skip to the next section).
_____ Yes _____ No
The program is an extended school day program that is conducted on the premises of an
accredited non-public school.
_____ Yes _____ No
The program is attended only by pupils enrolled in the school in which the program is being
conducted.
_____ Yes _____ No
The program is staffed by certified elementary school teachers.
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 SCHOOL AGE OR DROP IN PROGRAMS OWNED AND OPERATED BY A
LOCAL
UNIT OF GOVERNMENT (all other owners skip to the next section).
_____ Yes _____ No
The program is operated for no more than 4 consecutive hours or for no more than two
consecutive weeks.
I attest, under penalty of perjury, that to the best of my knowledge, the information in this section is true and correct.
______________________________________________________________________________
__________________
Signature of Official for the Local Unit of Government Authority
Date Signed
______________________________________________________________________________
Print title of position held with the local unit of government
SECTION VIII.
TO BE COMPLETED FOR ALL SCHOOL AGE OR DROP IN PROGRAMS REGARDLESS OF OWNER
_____ Yes _____ No
The program is an instructional class or activity in which a child or youth is enrolled for the
purpose of participating in only specific subject or skill-building area, including religious
instruction in a specific doctrine or tenet, academic or remedial instruction, basketball clinic,
baseball league, dance or drama class or class in martial arts?
_____ Yes _____ No
The public agency providing funding to the program requires the program to be licensed as a
child care facility.
_____ Yes _____ No
The program is a day reporting program for children 10 years of age or older and youth.
_____ Yes _____ No
The program is a specialized treatment, therapeutic, correctional, or rehabilitative program for
school age children or youth that children or youth attend 12 hours a week or more or more than
two consecutive weeks. Hours must be reflected in Section III above.
SECTION IX:
DESCRIPTION OF THE PROGRAM
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)
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