Form CCA-1260A "Back up Provider Application" - Arizona

What Is Form CCA-1260A?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Arizona Department of Economic Security;
  • 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 fillable version of Form CCA-1260A by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form CCA-1260A "Back up Provider Application" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1260A FORENG (7-19)
Page 1 of 2
Child Care Administration
BACK UP PROVIDER APPLICATION
BACKUP PROVIDER STATEMENT OF AGREEMENT
PLEASE CHECK ONE:
I am age 18 or older and understand the specific guidelines regarding my duties as outlined and in Article 52. I
understand that I must furnish proof of my immunization record and complete initial and annual TB tests. I am aware
that I am subject to a Department of Child Safety (DCS) clearance check and fingerprinting for a criminal background
investigation. I am aware that my ability to provide backup child care is contingent on both clearance through DCS
Clearance check and obtain a level one fingerprint clearance card. I understand that I must maintain current CPR/First
Aid Certification to provide backup services for the mentioned provider.
OR
I am the director/owner of a Department of Health Services (DHS) Licensed Child Care Center, DHS Group Home, or
DES Certified Provider. I am aware that my child care facility provides backup services to the mentioned provider.
DHS License Number (if applicable):
DES Provider ID (if applicable):
List ages certified or licensed to care for (list ages 0-12 years of age):
PLEASE COMPLETE ALL OF THE FOLLOWING SECTIONS:
I am available to provide backup services during the following days of the week and times:
Check Available Days of the Week:
MON
TUES
WED
THURS
FRI
SAT
SUN
List Available Hours (Starting hour-Ending hour, include AM and PM):
I may be contacted at:
Phone Number (include area code):
Physical Address (No., Street, Apt., City, State, ZIP Code):
I understand by signing below I am affirming that I have read and fully understand all the rules set forth by State of Arizona
Article 52 and agree to comply. I understand that an infraction of any rule or policy may cause revocation of my ability to
be a backup provider or hold a future DES Family Child Care Home Certificate including but not limited to the following:
I understand that I must meet the requirements for backup providers set forth in A.A.C. R-5-5202. I have read and further
understand the use of a Backup Provider as set forth in A.A.C. R6-5-5222.
I have read and understand the DES Discipline policy A.A.C. R-5-5212. I will comply with this policy while providing child
care.
I have read and fully understand the DES Transportation Policy as written in A.A.C. R6-5-5216 and agree to abide by this
policy. I agree not to transport children in care out of the United States. I further agree to not allow the children in care to
be transported in an uninsured vehicle or by an unlicensed driver while they are in my care, and I agree to call the child’s
parents or guardian immediately if there is an emergency and to call 911 if the emergency is life threatening.
BACKUP: I Will Be Transporting Children
Yes*
No
*If Yes is selected you MUST provide proof of current Arizona State Driver’s License, and vehicle liability insurance.
Backup Provider’s Signature:
Date:
Equal Opportunity Employer / Program • Auxiliary aids and services are available upon request to individuals with
disabilities • To request this document in alternative format or for further information about this policy, contact your local
office; TTY/TDD Services: 7-1-1 • Disponible en español en línea o en la oficina local
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1260A FORENG (7-19)
Page 1 of 2
Child Care Administration
BACK UP PROVIDER APPLICATION
BACKUP PROVIDER STATEMENT OF AGREEMENT
PLEASE CHECK ONE:
I am age 18 or older and understand the specific guidelines regarding my duties as outlined and in Article 52. I
understand that I must furnish proof of my immunization record and complete initial and annual TB tests. I am aware
that I am subject to a Department of Child Safety (DCS) clearance check and fingerprinting for a criminal background
investigation. I am aware that my ability to provide backup child care is contingent on both clearance through DCS
Clearance check and obtain a level one fingerprint clearance card. I understand that I must maintain current CPR/First
Aid Certification to provide backup services for the mentioned provider.
OR
I am the director/owner of a Department of Health Services (DHS) Licensed Child Care Center, DHS Group Home, or
DES Certified Provider. I am aware that my child care facility provides backup services to the mentioned provider.
DHS License Number (if applicable):
DES Provider ID (if applicable):
List ages certified or licensed to care for (list ages 0-12 years of age):
PLEASE COMPLETE ALL OF THE FOLLOWING SECTIONS:
I am available to provide backup services during the following days of the week and times:
Check Available Days of the Week:
MON
TUES
WED
THURS
FRI
SAT
SUN
List Available Hours (Starting hour-Ending hour, include AM and PM):
I may be contacted at:
Phone Number (include area code):
Physical Address (No., Street, Apt., City, State, ZIP Code):
I understand by signing below I am affirming that I have read and fully understand all the rules set forth by State of Arizona
Article 52 and agree to comply. I understand that an infraction of any rule or policy may cause revocation of my ability to
be a backup provider or hold a future DES Family Child Care Home Certificate including but not limited to the following:
I understand that I must meet the requirements for backup providers set forth in A.A.C. R-5-5202. I have read and further
understand the use of a Backup Provider as set forth in A.A.C. R6-5-5222.
I have read and understand the DES Discipline policy A.A.C. R-5-5212. I will comply with this policy while providing child
care.
I have read and fully understand the DES Transportation Policy as written in A.A.C. R6-5-5216 and agree to abide by this
policy. I agree not to transport children in care out of the United States. I further agree to not allow the children in care to
be transported in an uninsured vehicle or by an unlicensed driver while they are in my care, and I agree to call the child’s
parents or guardian immediately if there is an emergency and to call 911 if the emergency is life threatening.
BACKUP: I Will Be Transporting Children
Yes*
No
*If Yes is selected you MUST provide proof of current Arizona State Driver’s License, and vehicle liability insurance.
Backup Provider’s Signature:
Date:
Equal Opportunity Employer / Program • Auxiliary aids and services are available upon request to individuals with
disabilities • To request this document in alternative format or for further information about this policy, contact your local
office; TTY/TDD Services: 7-1-1 • Disponible en español en línea o en la oficina local
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CCA-1260A FORENG (7-19)
Page 2 of 2
Child Care Administration
REGISTRATION AND EMPLOYMENT HISTORY FOR
PROVIDING DES-CERTIFIED CHILD CARE SERVICES
Date:
Name of Person Being Fingerprinted (Last, First, M.I.):
Social Security Number:
Occupation:
Child Care Provider's Name (If different from above):
EMPLOYMENT HISTORY
Complete the following employment history. Start with your present or most recent job and go back five years. If
necessary, use an additional sheet and attach it to this form.
1. Employer's Name:
Job Title:
Employment Dates:
from:
to:
Address (No., Street, Suite No., City, State, ZIP Code):
Phone Number (with area code):
Reason for leaving:
2. Employer's Name:
Job Title:
Employment Dates:
from:
to:
Address (No., Street, Suite No., City, State, ZIP Code):
Phone Number (with area code):
Reason for leaving:
3. Employer's Name:
Job Title:
Employment Dates:
from:
to:
Address (No., Street, Suite No., City, State, ZIP Code):
Phone Number (with area code):
Reason for leaving:
I give my permission for the DES to contact the employers listed above.
Yes
No
If no, give reason:
Have you ever been employed to work with children?
Yes
No
If yes, list employer's name and address:
To your knowledge, have you ever been the subject of a Child Protective Services investigation?
Yes
No
If yes, explain:
Have you ever been fired or forced to resign from a job working with children?
Yes
No
If yes, explain:
Have you ever been a DES-certified child care home provider?
Yes
No
If yes, when and where:
STATEMENT OF PHYSICAL AND MENTAL HEALTH FOR FAMILY AND CHILD CARE PROVIDERS
I
am in good physical and mental health; I am able to perform all lawful duties of a
family child care provider. Also, I certify that I am free from all communicable diseases for which routine immunizations are
readily and safely available. I further agree to furnish such proof to that effect, as the Department of Economic Security
may require.
I further certify that all children 13 years old and younger residing in the provider’s home are also free of communicable
diseases for which routine immunizations are readily and safely available and shall furnish proof to the Department to that
effect or provide appropriate exemptions.
In the last 12 months, I have not
have
participated in counseling related to abuse or neglect of a child or for any
other violent behavior or act.
This statement does not supersede other requirements as stated in Arizona Administrative Code, Title 6, Chapter 5,
Article 52.
Backup Provider’s Signature:
Date:
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