Form CC59 "Child Care Center - Child Care Associate Reference" - Alaska

What Is Form CC59?

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

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Alaska Department of Health and Social 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 printable version of Form CC59 by clicking the link below or browse more documents and templates provided by the Alaska Department of Health and Social Services.

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Download Form CC59 "Child Care Center - Child Care Associate Reference" - Alaska

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Office Use Only
CHILD CARE LICENSING PROGRAM
Division of Public Assistance
Child Care Program Office
CHILD CARE CENTER – CHILD CARE ASSOCIATE REFERENCE
Child Care Associates of licensed child care centers are required to submit references from individuals who can
attest to their personal and professional reputable character, experience, ability to care for children, and ability
to operate a child care facility, if designated to do so in the absence of the Administrator.
The following reference information is needed for the Child Care Associate Applicant.
Name of Child Care Associate Applicant: __________________________________________
Name of Facility: ______________________________________________________________
Please answer the following questions regarding the Child Care Associate Applicant:
1. How long have you known this individual, and in what capacity?
2. Please explain how this individual has worked successfully with children and families, and acted as a
positive role model for children.
3. Please explain how this individual’s particular skills and abilities will support them to work successfully
with children, family members, department staff, community agencies, and staff of the child care facility.
4. Please explain how this individual has demonstrated the characteristics of a responsible individual of
reputable character, who exercises sound judgment.
5. Describe how you would feel about leaving a child in this individual’s care?
CC59 (06-4084) Rev. 02/18
http://dhss.alaska.gov/dpa/Pages/ccare/
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Office Use Only
CHILD CARE LICENSING PROGRAM
Division of Public Assistance
Child Care Program Office
CHILD CARE CENTER – CHILD CARE ASSOCIATE REFERENCE
Child Care Associates of licensed child care centers are required to submit references from individuals who can
attest to their personal and professional reputable character, experience, ability to care for children, and ability
to operate a child care facility, if designated to do so in the absence of the Administrator.
The following reference information is needed for the Child Care Associate Applicant.
Name of Child Care Associate Applicant: __________________________________________
Name of Facility: ______________________________________________________________
Please answer the following questions regarding the Child Care Associate Applicant:
1. How long have you known this individual, and in what capacity?
2. Please explain how this individual has worked successfully with children and families, and acted as a
positive role model for children.
3. Please explain how this individual’s particular skills and abilities will support them to work successfully
with children, family members, department staff, community agencies, and staff of the child care facility.
4. Please explain how this individual has demonstrated the characteristics of a responsible individual of
reputable character, who exercises sound judgment.
5. Describe how you would feel about leaving a child in this individual’s care?
CC59 (06-4084) Rev. 02/18
http://dhss.alaska.gov/dpa/Pages/ccare/
Page 1 of 2
6. Explain why you believe this individual is qualified to operate a licensed child care facility, if they were
designated to do so in the absence of the Administrator.
7. Explain this individual’s administrative and supervisory skills as it would relate to their leadership position
in a child care facility.
To your knowledge, has this individual:
8. Ever abused or neglected a child?
YES
NO
9. Been charged with or convicted of a serious crime?
YES
NO
To your knowledge, does this individual have:
10. A physical or behavioral problem that
poses a significant risk to children in care?
YES
NO
11. A domestic violence problem that poses a significant
risk to children in care?
YES
NO
If you answered YES to any of the questions 8-11, please explain.
12. Please include any additional comments and/or information you would like to share:
You may also contact the Child Care Program Office toll free at 1-888-268-4632 with any questions or
concerns. A Child Care Licensing Specialist may follow up with you regarding this reference.
___________________________________________
___________________________
Printed Name of Individual Providing Reference
Phone Number
___________________________________________
___________________________
Signature of Individual Providing Reference
Date
CC59 (06-4084) Rev. 02/18
http://dhss.alaska.gov/dpa/Pages/ccare/
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