Form 2910 "Application for a License or Certification to Operate a Child Day Care Facility" - Texas

What Is Form 2910?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • 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 2910 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Form 2910
June 2020-E
Application for a License or Certification to Operate a Child Day Care Facility
Use this form to apply for a license or certification to operate a child care center, school-age program, before or after-school
program, or child care home.
Directions: After completing this form, mail it and any other materials requested to your nearest Licensing office. For information
on local Licensing offices, see: https://hhs.texas.gov/services/safety/child-care/contact-child-care-licensing.
Part I – About Your Operation
Name of Operation
Area Code and Phone No.
Email Address
Address
City
County
State
ZIP Code
Mailing Address (if different)
City
County
State
ZIP Code
Hours of Operation ..................
Days of the Week in Operation
Months of the Year in Operation
Part II – Governing Body Information
Type of Governing Body:
Sole Proprietorship
Association
Corporation
Nonprofit Association
Nonprofit Corporation
State Operated
Political Subdivision
Partnership
Limited Partnership
Limited Liability Partnership
Limited Liability Company
Nonprofit Corporation with Religious Affiliation
Nonprofit Association with Religious Affiliation
Secretary of State Filing No. (if applicable)
Part III – Applicant Information
Section 1 ─ Complete this section if your type of governing body is a sole proprietorship or partnership. This includes a general,
limited partnership, or limited liability partnership.
If you have more than two partners, attach the information requested here for each.
Name of Entity (Required for a limited partnership or limited liability partnership.)
Name of Sole Proprietor or Partner
Area Code and Phone No.
Street Address or P.O. Box
Apartment No. City
County
State
ZIP Code
Name of Second Partner
Area Code and Phone No.
Street Address or P.O. Box
Apartment No. City
County
State
ZIP Code
Check here if you are (or a partner is) a military member, military spouse, military veteran or veteran spouse. This applies
only if your governing body is a sole proprietorship or partnership.
Form 2910
June 2020-E
Application for a License or Certification to Operate a Child Day Care Facility
Use this form to apply for a license or certification to operate a child care center, school-age program, before or after-school
program, or child care home.
Directions: After completing this form, mail it and any other materials requested to your nearest Licensing office. For information
on local Licensing offices, see: https://hhs.texas.gov/services/safety/child-care/contact-child-care-licensing.
Part I – About Your Operation
Name of Operation
Area Code and Phone No.
Email Address
Address
City
County
State
ZIP Code
Mailing Address (if different)
City
County
State
ZIP Code
Hours of Operation ..................
Days of the Week in Operation
Months of the Year in Operation
Part II – Governing Body Information
Type of Governing Body:
Sole Proprietorship
Association
Corporation
Nonprofit Association
Nonprofit Corporation
State Operated
Political Subdivision
Partnership
Limited Partnership
Limited Liability Partnership
Limited Liability Company
Nonprofit Corporation with Religious Affiliation
Nonprofit Association with Religious Affiliation
Secretary of State Filing No. (if applicable)
Part III – Applicant Information
Section 1 ─ Complete this section if your type of governing body is a sole proprietorship or partnership. This includes a general,
limited partnership, or limited liability partnership.
If you have more than two partners, attach the information requested here for each.
Name of Entity (Required for a limited partnership or limited liability partnership.)
Name of Sole Proprietor or Partner
Area Code and Phone No.
Street Address or P.O. Box
Apartment No. City
County
State
ZIP Code
Name of Second Partner
Area Code and Phone No.
Street Address or P.O. Box
Apartment No. City
County
State
ZIP Code
Check here if you are (or a partner is) a military member, military spouse, military veteran or veteran spouse. This applies
only if your governing body is a sole proprietorship or partnership.
Form 2910
Page 2 / 06-2020-E
Part III – Applicant Information
Section 2 ─ Complete this section if your type of governing body is an association, corporation, nonprofit association, nonprofit
corporation, political subdivision, nonprofit corporation with religious affiliation, nonprofit association with religious affiliation,
limited liability company, or state operated.
Name of Organization or Governing Body
Area Code and Phone No.
Street Address or P.O. Box
Apartment No. City
County
State
ZIP Code
Part IV – Child Population
Age Range:
To:
Expected Number of Children:
Part V – Operation Type and Services
Operation Type
Number of Children Served
Select One Type of Operation
For Licensed Child Care Centers only. Select one of the boxes
Licensed Child Care Center
Center with 12 or fewer children
Center with 13 or more children
School-Age Program (SAP)
N/A
Before or After-School Program (BAP)
N/A
Licensed Child Care Home
N/A
Part VI – Permit History
Do you (the applicant) have either a permit to provide any other type of child care or child-placing services, or a pending
application to provide such services?
Yes
No
If yes, specify the name of the operation and type of permit:
Is there a program exempt from Child Care Licensing regulation operating at the same physical location that you noted in Part I of
this application?
Yes
No
If yes, explain:
Have you (the applicant) ever been denied a permit to provide child care or child-placing services?...............
Yes
No
If yes, provide the date of denial: .....
Type of operation denied:
What was the reason for the revocation?
County
Operation's address (Street, City, State, and ZIP Code)
What was the reason for the denial?
Have you (the applicant) ever had a permit for child care or child-placing services revoked? .........................
Yes
No
If yes, provide the date of revocation:
Type of operation revoked:
County
Operation's address (Street, City, State, and ZIP Code)
If the revocation occurred in another state, list the name and address of the regulatory body that issued the revocation.
What is the reason for the revocation?
Form 2910
Page 3 / 06-2020-E
Part VI – Permit History
Have you (the applicant) ever been prohibited or barred from operating any other type of child care operation?
Yes
No
If yes, provide the date of the prohibition or bar:
Type of operation barred:
Operation's address (Street, City, State, and ZIP Code)
County
If the bar occurred in another state, list the name and address of the regulatory body that issued the bar:
What was the reason for the prohibition or bar?
Have you (the applicant) ever been a controlling person at an operation?........................................................
Yes
No
Was the operation's permit revoked?
Yes
No
If yes, provide the dates:
If so, provide the date of revocation.................................................................................................................
Name of the Operation:
Operation's address (Street, City, State, and ZIP Code)
County
Part VII – Additional Information for Publication on the Child Care Licensing (CCL) Website
Web Address http://:
Email Address
Services Provided (check all that apply)
School-Age Care
Field Trips
Accredited by National Organization
After School Services
Skills Classes
Get Well Care (for ill or recovering children)
Before School Services
Meals Provided
Snacks Provided
Children with Special Needs
Night Care
Child and Adult Care Food Program
Pool on Premises
Transportation
Water Activities
Drop-In Care (alternative care)
Part-Time Care (will enroll children for only part of the day and/or week)
Primary Language Spoken: ...................................................................................................................
Part VIII – Certification and Signature
I certify that the information provided here contains no willful misrepresentation or falsification and that it is true and complete to
the best of my knowledge and belief. I understand that any willful misrepresentation is cause for immediate denial of the
application or later denial or revocation of the license. The documentation to complete this application is attached (see the
checklist provided below). I understand that this application will be returned if the attached documentation is incomplete or does
not conform to applicable laws. If a license is granted, there will be no racial discrimination in the admission or care of children.
Signature of Applicant, Designee, or Head of the Governing Body
Date Signed
Form 2910
Page 4 / 06-2020-E
Part VIII – Certification and Signature
Proof of liability insurance or documentation that you are
unable to obtain liability insurance and a copy of the notice
Form 2948, Plan of Operation
to parents that informs them that you do not have liability
insurance. Note: Not required for Licensed Child Care
Homes.
Floor Plan (including dimensions of the indoor and outdoor
Form 3010, Licensed Child Care Fee Schedule
area)
Certificate of Good Standing or Formation (if applicable)
Form 2760, Controlling Person - Child Care Licensing
Request for Background Check(s)
Form 2911, Governing Body/Direction Designation
Form 2982, Personal History Statement (as needed)
Driving directions to the operation: Please provide clear and concise directions for driving to your operation from the nearest
Licensing office.
Privacy Statement
HHSC values your privacy. For more information, read the privacy policy online at:
https://hhs.texas.gov/policies-practices-
privacy#security
Form 2910
Page 5 / 06-2020-E
CCL Use Only
Date Application Received: ..............................................................................................................
Amendment Data
Amendment Data
Capacity (0-17 months): ........
Capacity (0-17 months): .........
Capacity (18 months or older):
Capacity (18 months or older):
Ages: ......................................
Ages: ......................................
Hours: .....................................
Hours: ....................................
Days: ......................................
Days: ......................................
Months: ..................................
Months: ..................................
Restrictions/Conditions: .........
Restrictions/Conditions: ........
Change requested: ................
Change requested: ................
Date Requested: ....................
Date Requested: ...................
Date Fee Paid: ........................
Date Fee Paid: ........................
Amount Paid (if applicable):
Amount Paid (if applicable):
Method of Verification:
Method of Verification:
By: ........................................
By: ........................................
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