REQUEST FOR A REGISTRATION PERMIT child care licensing (CCL)

Purpose: Use this form to apply for a registration permit to operate a registered child-care home
Directions: After completing this form, please mail it and any other materials requested to your nearest DFPS Licensing office. For information on local Licensing offices, see: http://www.dfps.state.tx.us/Child_Care/Local_Child_Care_Licensing_Offices/default.asp Part I – APPLICANT INFORMATION | Name (First, Middle, Last): Other Names You Have Used or Have Been Known By (maiden, married, etc.): | Date of Birth: | Social Security Number (Indicate if you do not have a Social Security number): Texas Driver License or State ID Number (Indicate if you do not have a Texas driver's license or if you have an out-of-state driver's license): | Home Telephone Number: Cell Telephone Number: Contact Email: | Location Street Number | Location Street Address | Apartment Number | City | County | State | Zip Code | Mailing Address (if different) - Street or PO Box and Zip Code | Check here if you are a military service member, military spouse, or military veteran | Check here if you are currently a foster parent |

Part II – EDUCATION AND TRAINING | Did you graduate high school or receive a GED? (Please attach a photocopy of your high school diploma, college diploma, or GED certificate) Yes No If you are under 21 years of age, describe any training, education, accreditation, and/or course study you have had which qualifies you according to 40 TAC 747.1013. Give dates, locations, and name of the organization or agency sponsoring the training (Please attach photocopies of supporting documentation) |

Part III – HOME INFORMATION | Hours of Operation: Days of the Week in Operation: Months of the Year in Operation: | The following people (spouse, children, friends, etc.) live in the home or are regularly or frequently present in the home: Name | Age | Date of Birth | Social Security Number | TX Driver License No. | Relationship | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Will any people assist you in caring for children? Yes No If yes, provide the following information on the people who will assist you (include their names on Form 2971) Name | Social Security Number | TX Driver License No. | Date of Birth | | | | | Street Address | City | Zip Code | Telephone No. | | | | | Name | Social Security Number | TX Driver License No. | Date of Birth | | | | | Street Address | City | Zip Code | Telephone No. | | | | | | Have you or has any person living in your home, anyone who helps care for children, or anyone who will have contact with the children in your care (other than a child's family) ever had one of the following: A child removed because of abuse or neglect? Yes No A determination that a child was abused or neglected? Yes No A contact or visit regarding child abuse or neglect by any of the following agencies: Child Protective Services with DFPS? | Yes No | Child welfare agency anywhere in Texas or another state? | Yes No | Law enforcement agency (police, sheriff, etc.) in Texas or another state? | Yes No | Other (specify) | Yes No | If yes to any of the questions above, what was the child's name? How was the child related to you? When did this occur? Where did this occur? Comments: | Do you or does any person living in your home, anyone who helps care for children, or anyone who will have contact with the children in your care (other than a child's family) have any of the following: A felony conviction? Yes No If yes, give the name of the person, type of conviction, date of conviction, location of the offense, and details of the offense: A felony or misdemeanor charge pending? Yes No If yes, give the name of the person, type of charge, location of the offense, county where the charge is pending, court number, and details of the offense A deferred sentence? Yes No If yes, give the name of the person, type of charge, location of the offense, county where the charge is pending, court number, and details of the offense | List any health problems that you or a family member has that would affect or limit your ability to care for children: |

Part IV – CHILD POPULATION | Are you now caring for children in your home who are not related to you? Yes No | How many children are you caring for or do you intend to care for? (Count all children, including those related to you.) Birth through 17 months: 18 months through 2 years: 3 years through 4 years: 5 years and older: Total number of children (including your own children under 14 years): | If you are caring for children who are related to you, state the children's full names, ages, and relationships below. Name | Age | Relationship | | | | | | | | | | | | | |

Part V – 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: | 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 | Operation’s address (Street, City, State, and Zip Code): | County | 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 date of the revocation: | Type of operation revoked? | Operation’s address (Street, City, State, and Zip Code): | County | If the revocation occurred in another state, list the name and address of the regulatory body that issued the revocation: | What was the reason for the revocation? | 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) or your spouse ever been a controlling person at an operation? Yes No | If yes, provide the dates: | Was the operation’s permit revoked? If so, provide the date of revocation: | Name of the operation: | Operation’s address (Street, City, State, and Zip Code): | County |

Part VI – ADDITIONAL INFORMATION FOR PUBLICATION ON THE DFPS WEBSITE | Website 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 | | Subsidized Child Care | | Night Care | | Child and Adult Care Food Program | | Children with Special Needs | | Transportation | | Water Activities | | Pool on Premises | | Drop-In Care (Alternative Care) | | Part-Time Care (will enroll children for only part of the day or week) | Primary Language Spoken: |

Part VII – 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 registration permit. 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 registration permit is granted, there will be no racial discrimination in the admission or care of children. | Signature of Applicant X | Date Signed: | | Verification of Fee Payment (Form 3009) | | Notarized Affidavit for Applicants for Employment (Form 2985) for any of your employees | | Proof of current certification in infant/child/adult CPR | | Proof of current certification in First Aid which includes rescue breathing and choking | | Proof of the completion of orientation within one year before the application date | | Controlling Person Form (Form 2760) or the online submission of information regarding controlling persons through the DFPS website | | Request for Background Checks (Form 2971) | | Proof of high school diploma or high school equivalent |

DRIVING DIRECTIONS TO THE OPERATION: (Please provide clear and concise directions for driving to your home located in a rural area) | PRIVACY STATEMENT | DFPS values your privacy. For more information, read our privacy policy online at http://www.dfps.state.tx.us/policies/privacy.asp. |

DFPS USE ONLY | Date Application Received: | Date Application Accepted: | Date Fee Verified: | Amount Paid: | Method of Verification: | By: | |