Form DPHHS-QAD-CCL Change of Name / Address / Ages for Registration / License Certificate Infant, Family, Group, and Center Day Care Facility - Montana

Form DPHHS-QAD-CCL or the "Change Of Name / Address / Ages For Registration / License Certificate Infant, Family, Group, And Center Day Care Facility" is a form issued by the Montana Department of Public Health and Human Services.

The form was last revised in November 1, 2017 and is available for digital filing. Download an up-to-date Form DPHHS-QAD-CCL in PDF-format down below or look it up on the Montana Department of Public Health and Human Services Forms website.

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STATE OF MONTANA
DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES
DIVISION OF QUALITY ASSURANCE
CHANGE OF NAME / ADDRESS / AGES
FOR REGISTRATION / LICENSE CERTIFICATE
INFANT, FAMILY, GROUP, and CENTER DAY CARE FACILITY
Director / Provider Name
Phone #
Facility Name
PV #
Date that the change is effective:
Please indicate the type of change that this is:
[ ] Name: Please list old name:
Please list new name:
[ ] Address Change / New Phone #: Please list new address*
OLD Physical Address
Street
City
State
Zip
OLD Mailing Address
Street
City
State
Zip
NEW Physical Address
Street
City
State
Zip
NEW Mailing Address
Street
City
State
Zip
Directions to day care site (From the nearest major street or highway)
* If you are moving to a new location you will need to complete a new floor plan, square footage form, and
provide us with a copy of your Public Liability and Fire insurance showing the new address and effective date.
[ ] Phone #:
Old:
New:
[ ] Ages: Please list the ages you are now caring for:
Please list the ages that you wish to care for*:
*If you now want to care for infants, but you were not previously, please read “The Infant Day Care Regulations.”
Hours of operation (days and hours): Old:
New:
1
STATE OF MONTANA
DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES
DIVISION OF QUALITY ASSURANCE
CHANGE OF NAME / ADDRESS / AGES
FOR REGISTRATION / LICENSE CERTIFICATE
INFANT, FAMILY, GROUP, and CENTER DAY CARE FACILITY
Director / Provider Name
Phone #
Facility Name
PV #
Date that the change is effective:
Please indicate the type of change that this is:
[ ] Name: Please list old name:
Please list new name:
[ ] Address Change / New Phone #: Please list new address*
OLD Physical Address
Street
City
State
Zip
OLD Mailing Address
Street
City
State
Zip
NEW Physical Address
Street
City
State
Zip
NEW Mailing Address
Street
City
State
Zip
Directions to day care site (From the nearest major street or highway)
* If you are moving to a new location you will need to complete a new floor plan, square footage form, and
provide us with a copy of your Public Liability and Fire insurance showing the new address and effective date.
[ ] Phone #:
Old:
New:
[ ] Ages: Please list the ages you are now caring for:
Please list the ages that you wish to care for*:
*If you now want to care for infants, but you were not previously, please read “The Infant Day Care Regulations.”
Hours of operation (days and hours): Old:
New:
1
DAY CARE LOCATION:
Is the day care located in your residence? [ ] Yes
] No
If Yes, Please complete both the Household Member table and the Caregivers table
If No, you only need to complete the Caregivers table.
*
If you are renting please make sure it is okay with your landlord to provide day care on the rental property.
HOUSEHOLD MEMBERS
*In the space provided below please include the name and birth date, of all persons presently living in the home,
where day care will be provided. (Please include yourself, if you reside there)
Name
Date Of Birth
Relationship
1
2
3
4
5
CAREGIVERS
Please list the names, addresses, and phone number of all persons responsible for the direct care and supervision
of children in your facility.
WORKS 160 Hrs/Yr
PS#
NAME
POSITION
(From PS#
Card)
More Than Less Than
1
2
3
4
EDUCATION AND EXPERIENCE
Elementary of High School (Circle years completed)
/
Did you graduate or receive GED…
1 2 3 4 5 6 7 8 9 10 11 12
[ ] Yes
[ ] No
College
more than 5
1 2 3 4
Degree(s)
Describe any experience and training you have had in the care and supervision of children. Give dates,
locations and names of any organizations or agencies, which you worked for:
2
In Accordance with the Montana Child Care Act, (52-2-702-714), Montana Code Annotated, I hereby request the
re-issuance of an Infant, Family, Group, or Day Care Center Certificate of Registration / License on the basis of
my affirmation of the following statements:
Please
Initial
a.
I have received and have read a copy of the State Regulations for Family Group Day Care Homes,
Day Care Centers and Infant Care.
b. I certify, to the best of my knowledge and belief that, I will be in compliance with the State
Regulations for Family/Group Day Care Homes, Day Care Centers, and Infant Care, while
children are in care.
c.
I understand that I cannot care for more children at any one time than are indicated by the
Registration/License Certificate. This number includes my own children under the age of 6 years.
d.
I understand that any complaints about my registered/licensed day care facility may be investigated
by a representative of the Department, without prior notification.
e.
I understand that my registered/licensed day care facility may be visited, and I will allow worker
entry.
f.
If I move to another address or stop providing care to children I must notify the Department of
Public Health and Human Services, Child Care Licensing Program.
g.
I understand that the name and address of my registered day care home will appear on a list which
is maintained by the Department of Public Health and Human Services
h.
I will keep the necessary Insurance in force covering the total number of children I am caring for.
I certify that I have adequate Public Liability and Fire Insurance for the purpose of conducting
child day care. Your insurance agent must complete the “Insurance Verification Form”. If
you are renting we need a copy of your landlord’s Fire Insurance and written approval from your
landlord that he does not mind you providing day care services.
i.
I will provide the department with the names, addresses, phone numbers, and parents’ names,
of each child in my care whenever requested to do so by the department.
To the best of my knowledge and belief, all information I have given to the Department of Public Health and
Human Services and/or its authorized agents on this form is true and correct. I will supply true and correct
information requested during all subsequent contacts.
(Signature)
(Date)
DPHHS-QAD-CCL 11/17
3
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