"Family Child Care Home Renewal License Application" - Delaware

Family Child Care Home Renewal License Application is a legal document that was released by the Delaware Department of Services for Children, Youth and their Families - a government authority operating within Delaware.

Form Details:

  • Released on March 1, 2019;
  • The latest edition currently provided by the Delaware Department of Services for Children, Youth and their Families;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Delaware Department of Services for Children, Youth and Their Families.

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S
D
TATE OF
ELAWARE
OFFICE USE ONLY
Please Print
D
S
C
, Y
T
F
EPARTMENT OF
ERVICES FOR
HILDREN
OUTH AND
HEIR
AMILIES
O
C
C
L
(OCCL)
FFICE OF
HILD
ARE
ICENSING
all responses.
F
C
C
H
Licensing specialist:
________
AMILY
HILD
ARE
OME
Date received:
R
L
A
ENEWAL
ICENSE
PPLICATION
License number: _______ License expiration date: ____/____/____
SECTION A – Identification
Applicant name:
Date of birth:
Race:
Alias, maiden, or married names this person has used:
Location address:
(street)
(city)
(county)
(state)
(zip)
Applicant cell phone #:
Location phone #:
Email address:
Fax #:
Entity Information (optional)
The “entity” is the individual, LLC, or corporation that is responsible for and has authority over the operation of the facility. If there is an
entity, the applicant must still have responsibility for the facility, reside in the facility, provide the child care, and control the space. If no
entity has been formed, check “individual” and leave the rest of this section blank.
Individual
Corporation
Entity name:
Entity type:
Limited liability company (LLC)
Doing business as/facility name:
Entity address:
(street)
(city)
(state)
(zip)
If the entity is an LLC, provide on a separate page a name, address, and phone number for the managing member.
1.
If the entity is a corporation, provide on a separate page a name, address, and phone number for each corporate officer.
2.
Please submit:
certificate of incorporation or LLC, if applicable and
a Delaware state business license or
3.
proof of non-profit status (for example, letter of tax-exempt status or 501(c)(3) documents).
SECTION B – Additional Information
Household member(s) other than the applicant (anyone staying in the home for more than 30 days within a year, or whose
current driver’s license/state ID is issued to the address listed on this application)
Full name
Alias, maiden, or married names this person has used
Date of birth
Race
Gender
S
D
TATE OF
ELAWARE
OFFICE USE ONLY
Please Print
D
S
C
, Y
T
F
EPARTMENT OF
ERVICES FOR
HILDREN
OUTH AND
HEIR
AMILIES
O
C
C
L
(OCCL)
FFICE OF
HILD
ARE
ICENSING
all responses.
F
C
C
H
Licensing specialist:
________
AMILY
HILD
ARE
OME
Date received:
R
L
A
ENEWAL
ICENSE
PPLICATION
License number: _______ License expiration date: ____/____/____
SECTION A – Identification
Applicant name:
Date of birth:
Race:
Alias, maiden, or married names this person has used:
Location address:
(street)
(city)
(county)
(state)
(zip)
Applicant cell phone #:
Location phone #:
Email address:
Fax #:
Entity Information (optional)
The “entity” is the individual, LLC, or corporation that is responsible for and has authority over the operation of the facility. If there is an
entity, the applicant must still have responsibility for the facility, reside in the facility, provide the child care, and control the space. If no
entity has been formed, check “individual” and leave the rest of this section blank.
Individual
Corporation
Entity name:
Entity type:
Limited liability company (LLC)
Doing business as/facility name:
Entity address:
(street)
(city)
(state)
(zip)
If the entity is an LLC, provide on a separate page a name, address, and phone number for the managing member.
1.
If the entity is a corporation, provide on a separate page a name, address, and phone number for each corporate officer.
2.
Please submit:
certificate of incorporation or LLC, if applicable and
a Delaware state business license or
3.
proof of non-profit status (for example, letter of tax-exempt status or 501(c)(3) documents).
SECTION B – Additional Information
Household member(s) other than the applicant (anyone staying in the home for more than 30 days within a year, or whose
current driver’s license/state ID is issued to the address listed on this application)
Full name
Alias, maiden, or married names this person has used
Date of birth
Race
Gender
SECTION B – Additional Information, continued
Substitute(s)
Alias, maiden, or married
Emergency or non-
Full name
Date of birth
Race
Gender
names this person has used
emergency use
CHU contact
Please provide the email at which you prefer to receive the fingerprinted background check results from the Criminal History
Unit (CHU). The results will contain confidential information about each person’s eligibility for employment or to reside at
a licensed child care facility.
CHU contact name:
Email:
SECTION C – Current Enrollment
Child’s name (FIRST NAME ONLY)
Date of birth
Days attending
Hours attending each day
Example:
Dante
5/22/10
Monday - Friday
8:00 a.m. - 5:00 p.m.
7:00 a.m. – 8:15 a.m
Example:
Kate
11/6/09
Monday - Friday
3:15 p.m. – 5:45 p.m.
SECTION D – Program Information
Hours of operation:
Days of operation:
Months of operation:
_____ a.m. – _____ p.m. or a.m. (circle one)
M
T
W
Th
F
Sa
Su
January to December
_____ p.m. – _____ p.m.
August to June
_______ to _______
Ages of children accepted: (Use “kindergarten” for 5-year-olds attending kindergarten. Otherwise, use exact ages.)
Example: From 6 weeks to 12 years From ___________________ to ___________________
Program components:
Purchase of Care
Transportation:
field trips
daily
other
Food program (CACFP) agency:
Other (specify):
Are you currently licensed or approved or applying to provide foster care or kinship care?
Yes
No
Revised March 2019
Page 2 of 3
SECTION E – Certification and Signature
I have read, understand, and will follow DELACARE: Regulations for Family and Large Family Child Care Homes.
I understand that the Department of Services for Children, Youth and Their Families, Office of Child Care Licensing, is
required under Delaware law to make a thorough investigation to determine the good character and intention of the
applicant or applicants, that the individual home or facility meets the physical, social, moral, mental and educational
needs of the average child, that the required criminal background checks are completed and approved, and whether the
regulations and requirements of OCCL are properly met. That may consist of announced or unannounced on-site review
of the program and contacting of references submitted as well as other persons or agencies that may have information
pertinent to making the determination that the applicant has met the requirements for licensing.
I certify that to the best of my knowledge the applicant, substitutes, and household members do not have any conviction,
current indictment, or arrest involving violence against a person; child abuse or neglect; possession, sale, or distribution
of illegal drugs; sexual misconduct; or gross irresponsibility or disregard for the safety of others. I further certify if I
have knowledge of any convictions, indictments, or arrests involving any of the persons cited above, I will promptly
notify OCCL.
I certify that to the best of my knowledge, the applicant, substitute, and household members have not lost custody of
their own child or any child placed in their care; been diagnosed or under treatment for any serious mental illness; or has
a current or former addiction to drugs or alcohol. I further certify if any of the above incidents occur, involving any of
the persons cited above, I will promptly notify OCCL.
I agree that identifying information, including my name, address, and contact information, license status, enforcement
action, non-compliances, and substantiated complaints will be made available to the public through a variety of means,
including via the OCCL website.
I agree to comply with all federal, state, and local laws and regulations.
I certify that to the best of my knowledge all information I have given to OCCL is true and correct. I will continue to
supply true and correct information. Submitting false information or failing to provide complete information when
requested may result in warning of probation, probation, suspension, revocation of the license, or denial of a license
application.
_______________________________________________________________
__________________________________________________
Signature of applicant from page 1
Date
STATE OF DELAWARE
)
: SS
COUNTY OF ___________
)
Signed and attested before me this ____________________________________________________.
Date
____________________________________________________________
__________________________________________________
Signature of notarial officer
Print name
(seal)
Revised March 2019
Page 3 of 3
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