Form MO580-3052 (BCC-71A) "Child Care Work Experience" - Missouri

Form MO580-3052 is a Missouri Department of Health and Senior Services form also known as the "Form Mo580-3052 (bcc-71a) "child Care Work Experience" - Missouri". The latest edition of the form was released in April 1, 2017 and is available for digital filing.

Download an up-to-date Form MO580-3052 in PDF-format down below or look it up on the Missouri Department of Health and Senior Services Forms website.

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Download Form MO580-3052 (BCC-71A) "Child Care Work Experience" - Missouri

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
Send to:
Section for Child Care Regulation
SECTION FOR CHILD CARE REGULATION
Director Certification
PRINT
P.O. Box 570
CHILD CARE WORK EXPERIENCE
Jefferson City, MO 65102
RESET
INSTRUCTIONS
• This form is used to document a director applicant’s child related work experience needed to meet licensing rules.
• The experience must have been responsible, supervisor, full-time (a minimum of 35 hours per week), paid experience in working with
children in a child care setting. Part time experience may be prorated.
• Each month of full-time experience may be substituted for two (2) college semester hours in unspecified courses but NOT for the required
child related courses.
• In-home experience must have been in a licensed family home. Facility DVN must be provided.
• Foster care and administrative work does not count toward experience credits.
• A Child Care Work Experience form must be submitted for each facility/employer.
NAME OF APPLICANT
SOCIAL SECURITY NUMBER
NAME OF FACILITY/EMPLOYER
FACILITY DVN (LICENSE NUMBER)
FACILITY ADDRESS
CITY
STATE
ZIP CODE
SUPERVISOR NAME
FACILITY TELEPHONE NUMBER
(
)
APPLICANT JOB TITLE
AGES OF CHILDREN SERVED
DATE(S) OF EMPLOYMENT (DAY/MONTH/YEAR)
FROM:
/
/
TO:
/
/
NUMBER OF HOURS PER WEEK
NUMBER OF MONTHS PER YEAR
EMPLOYEE’S JOB DUTIES
THE INFORMATION SUBMITTED ON THIS FORM IS TRUE AND ACCURATE.
SIGNATURE OF APPLICANT
PRINTED NAME
DATE
SCCR OFFICE USE ONLY
TOTAL MONTHS OF CHILD CARE RELATED EXPERIENCE
COLLEGE CREDIT EQUIVALENCY
MO 580-3052 (04/17)
BCC-71A
SAVE
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
Send to:
Section for Child Care Regulation
SECTION FOR CHILD CARE REGULATION
Director Certification
PRINT
P.O. Box 570
CHILD CARE WORK EXPERIENCE
Jefferson City, MO 65102
RESET
INSTRUCTIONS
• This form is used to document a director applicant’s child related work experience needed to meet licensing rules.
• The experience must have been responsible, supervisor, full-time (a minimum of 35 hours per week), paid experience in working with
children in a child care setting. Part time experience may be prorated.
• Each month of full-time experience may be substituted for two (2) college semester hours in unspecified courses but NOT for the required
child related courses.
• In-home experience must have been in a licensed family home. Facility DVN must be provided.
• Foster care and administrative work does not count toward experience credits.
• A Child Care Work Experience form must be submitted for each facility/employer.
NAME OF APPLICANT
SOCIAL SECURITY NUMBER
NAME OF FACILITY/EMPLOYER
FACILITY DVN (LICENSE NUMBER)
FACILITY ADDRESS
CITY
STATE
ZIP CODE
SUPERVISOR NAME
FACILITY TELEPHONE NUMBER
(
)
APPLICANT JOB TITLE
AGES OF CHILDREN SERVED
DATE(S) OF EMPLOYMENT (DAY/MONTH/YEAR)
FROM:
/
/
TO:
/
/
NUMBER OF HOURS PER WEEK
NUMBER OF MONTHS PER YEAR
EMPLOYEE’S JOB DUTIES
THE INFORMATION SUBMITTED ON THIS FORM IS TRUE AND ACCURATE.
SIGNATURE OF APPLICANT
PRINTED NAME
DATE
SCCR OFFICE USE ONLY
TOTAL MONTHS OF CHILD CARE RELATED EXPERIENCE
COLLEGE CREDIT EQUIVALENCY
MO 580-3052 (04/17)
BCC-71A
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