Form CCL209 "Notification of Change in Program Director" - Kansas

What Is Form CCL209?

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 May 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 CCL209 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 CCL209 "Notification of Change in Program Director" - Kansas

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Kansas Department of Health and Environment
CCL 209
Rev. 5/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Child Care Program:
(785) 296 -1270 Fax: (785) 559 -4244
Website: www.kdheks.gov/kidsnet
NOTIFICATION OF CHANGE IN PROGRAM DIRECTOR
PLEASE NOTE: If your facility currently uses the KDHE Online Application Portal, please login online and submit a “Modify
Affiliate” application to make the Program Director change making sure you have only ONE Program Director
listed. If this change is submitted online, please do not submit this form.
* ALL boxes below must be completed to process the Program Director Change *
Name of facility exactly as stated on the license.
License #
Street Address of Facility
City
Zip Code
County
NEW PROGRAM DIRECTOR INFORMATION
First and Last Name
KDHE Certificate # (if applicable)
Effective date as the new Program Director
Qualified for a total capacity of
Total facility capacity
(MM/DD/YYY)
Is the new Program Director currently affiliated with this facility? YES _____ *NO ______
*If NO, a KBI/DCF form is required to be completed and attached to this form.
CURRENT OR PREVIOUS PROGRAM DIRECTOR INFORMATION
First and Last Name
Still employed at the facility? *YES _____ NO _____
If YES, what is their new role (ex. Employee, Assistant
Director, etc.)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Signature of Authorized Person
Date Signed (MM/DD/YYYY)
Kansas Department of Health and Environment
CCL 209
Rev. 5/2017
Bureau of Family Health
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Child Care Program:
(785) 296 -1270 Fax: (785) 559 -4244
Website: www.kdheks.gov/kidsnet
NOTIFICATION OF CHANGE IN PROGRAM DIRECTOR
PLEASE NOTE: If your facility currently uses the KDHE Online Application Portal, please login online and submit a “Modify
Affiliate” application to make the Program Director change making sure you have only ONE Program Director
listed. If this change is submitted online, please do not submit this form.
* ALL boxes below must be completed to process the Program Director Change *
Name of facility exactly as stated on the license.
License #
Street Address of Facility
City
Zip Code
County
NEW PROGRAM DIRECTOR INFORMATION
First and Last Name
KDHE Certificate # (if applicable)
Effective date as the new Program Director
Qualified for a total capacity of
Total facility capacity
(MM/DD/YYY)
Is the new Program Director currently affiliated with this facility? YES _____ *NO ______
*If NO, a KBI/DCF form is required to be completed and attached to this form.
CURRENT OR PREVIOUS PROGRAM DIRECTOR INFORMATION
First and Last Name
Still employed at the facility? *YES _____ NO _____
If YES, what is their new role (ex. Employee, Assistant
Director, etc.)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Signature of Authorized Person
Date Signed (MM/DD/YYYY)