Form CCL.205 "Licensed Day Care/Group Day Care Home" - Kansas

What Is Form CCL.205?

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.205 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.205 "Licensed Day Care/Group Day Care Home" - Kansas

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CCL. 205
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: (785) 296-1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
LICENSED DAY CARE/GROUP DAY CARE HOME
INSTRUCTIONS: Record each child’s name. Include the provider’s own children under eleven years of age and any children for which an exception is requested (if requesting an
exception to exceed capacity). Provide each child’s date of birth, date of enrollment, hours in care, and the days in care. Draw a line from the time the child arrives to the time the child leaves.
All information must be complete. Incomplete forms will be returned.
________________________________________________________________________________________________________________________________________________________________________
Name of Facility (exactly as it appears on the license)
License Number
County
Street Address
City
Zip Code
Phone Number
Email
Name of Child
Date of
Date of
Day(s) of
Including First and
Enroll-
Hours
Birth
Week
Last Name
ment
7:30am-
← -
- →
Jane Doe
2/8/2011
1/15/2013
MTWThF
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
4:30pm
I attest that the above information is true and correct.
Provider’s Signature ____________________________________________________________________________
Date _________________________________
CCL. 205
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: (785) 296-1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
LICENSED DAY CARE/GROUP DAY CARE HOME
INSTRUCTIONS: Record each child’s name. Include the provider’s own children under eleven years of age and any children for which an exception is requested (if requesting an
exception to exceed capacity). Provide each child’s date of birth, date of enrollment, hours in care, and the days in care. Draw a line from the time the child arrives to the time the child leaves.
All information must be complete. Incomplete forms will be returned.
________________________________________________________________________________________________________________________________________________________________________
Name of Facility (exactly as it appears on the license)
License Number
County
Street Address
City
Zip Code
Phone Number
Email
Name of Child
Date of
Date of
Day(s) of
Including First and
Enroll-
Hours
Birth
Week
Last Name
ment
7:30am-
← -
- →
Jane Doe
2/8/2011
1/15/2013
MTWThF
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
4:30pm
I attest that the above information is true and correct.
Provider’s Signature ____________________________________________________________________________
Date _________________________________