Nevada > Statewide > Division Of Child And Family Services > Adoption
Initial Application For Family Or Group Child Care License - Nevada
| Initial Application For Family Or Group Child Care License Form. This is a Nevada form and can be used in Adoption Division Of Child And Family Services Statewide . |
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STATE OF NEVADA DEPARTMENT OF HUMAN RESOURCES DIVISION OF CHILD AND FAMILY SERVICES BUREAU OF SERVICES FOR CHILD CARE LAS VEGAS OFFICE ELKO OFFICE CARSON CITY OFFICE 4180 S Pecos Road Suite 150 Las Vegas, Nevada 89121 Phone: 702-486-7918 Fax: 702-486-6660 1010 Ruby Vista Drive Suite, 101 Elko, Nevada 89801 Phone: 775-753-1237 Fax: 775-753-1336 4150 Technology Way, 3rd Floor Carson City, Nevada 89706 Phone: 775-684-4463 Fax: 775-684-4464 INITIAL APPLICATION FOR FAMILY/GROUP CHILD CARE LICENSE All applications must be complete, signed, notarized and returned to the appropriate office referenced above. Any application that is incomplete i.e. not signed and/or not notarized will be returned without processing. THE FACILITY/AGENCY MAY NOT BEGIN OPERATION WITHOUT A LICENSE ISSUED. LICENSES ARE NOT TRANSFERABLE FROM ONE OWNER TO ANOTHER AND ARE VALID ONLY FOR THE PREMISES DESCRIBED ON THE LICENSE. ANY CHANGE OF RESIDENCE REQUIRES THE SUBMISSION AND APPROVAL OF ANOTHER APPLICATION WITH INSPECTIONS COMPLETED BEFORE ANOTHER LICENSE MAY BE ISSUED. FEE SCHEDULE $ 20.00 $60.00 AMOUNT ENCLOSED $ $ Family Care Home for 5 to 6 children Group Care Home for 7 to 12 children 1. IDENTIFYING INFORMATION: Owner: ___________________________________________________________________________________________________ Child Care Name: ___________________________________________________________________________________________ Physical Address:_____________________________ City:___________________ State: _________________ Zip:______________ Mailing Address if different from physical address:_________________________________________________________________ Telephone:___________________________ Fax:______________________ Email:____________________ Pager:____________ Citizenship:_______________________ If not U.S., explain: ________________________________________________________ After hours contact information for the owner: Same as above Telephone: Email: _____________________ In times of emergencies, the Bureau may need to reach the owner/director to relay important information. List all residents in the home: (including yourself) NAME BIRTH DATE SOCIAL SECURITY RELATIONSHIP GENDER 2. ACTION REQUESTED: INITIAL APPLICATION/LICENSE Check one Home is: Owned Leased Rented Note: For rented or leased homes, written permission of property owner is required for licensure. Is facility a manufactured home? NO YES Year of manufacture: __________________ 3. TYPE OF LICENSE: Number of requested spaces for children: Ages of children: Check all that apply Family Care Family Care __ 5-6 ___ to ___ Group Care Group Care __ 7-12 ___ to ___ Before/After School Care Before/After School Care __ 1-3 6 to ___ Note: Providers own children under age 11 are included in the before & after school count. Care must be provided before & after normal school hours only and must not exceed 3 consecutive hours (does not include school holidays, teacher workdays, summer vacations, etc.). Kindergartner children are not included in the before & after school count. AND ___ to ___ Preschool Preschool (Complete only if licensed as preschool) __________ Other________ ___ to ___ Other Director Application(s): Check all that apply Submitted for: Preschool Program Director: ______________________________________________________________________________ Other Director: (EXPLAIN) ______________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Posted 1/31/2011 Revised 1/08 Each of the persons listed in this application have attested to the applicant that they have no pending charges and: a) Have never been convicted of a felony; b) Have never been in violation of any federal or state law regulating child abuse and/or neglect or contributory delinquency; c) Have never been in violation of any federal or state law regulating the possession, distribution or use of any controlled substance or any dangerous drugs as defined in chapter 454 of NRS; d) Have never been in violation of any federal or state law regarding murder, manslaughter or mayhem; any other violation involving the use of a firearm or other deadly weapon; assault with intent to kill or to commit sexual assault or mayhem; sexual assault, statutory sexual seduction, incest, lewdness, indecent exposure or any other sexually related crime; e) Have never been found in violation of any local, state or federal law which arises from or is otherwise related to the individual's relationship to a child care facility; f) Have not currently or in the past had previous interest in a licensed child care facility that has been any of the following: (i) Closed as a result of a license suspension or revocation; (ii) Involuntarily terminated for any reason; or (iii) Convicted of child abuse, neglect or exploitation. g) Convicted of any other crime involving physical harm to a person or if a criminal action is pending against the person. 4. IF YOU, AS THE APPLICANT, OWNER (S) OR ANY PERSON 18 YEARS OR OLDER, LIVING ON THE CHILD CARE FACILITY PREMISES, VOLUNTEERS OR ALTERNATE CARETAKERS HAVE EVER BEEN ARRESTED OR CONVICTED OF ANY CRIMES, REGARDLESS OF WHEN OCCURRED, IDENTIFY THE PERSON BY NAME, RELATIONSHIP, BIRTH DATE, CRIME, STATE OF ARREST OR CONVICTION, AND DATE OF ARREST (S) OR CONVICTION (S) AND DISPOSITION OF ARREST (S). __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ FINGERPRINTS SUBMITTED IN NEVADA FOR ALL PERSONS, 18 YEARS OF AGE OR OLDER, IDENTIFIED IN THIS APPLICATION: YES NO If no, explain. Date and location where prints were submitted: _________________________________________________________________ (The licensee must regularly provide care for the children enrolled in a family or group care home.) A complete listing of all residents residing in the home or on the premises of the home when children are in care must be provided. This listing must be submitted on the form designated by the Bureau. The Bureau must be immediately notified of any additional person employed or leaving employment or residing in the home. NUMBER OF STAFF EMPLOYED: _____________________________ (Group Care Only) NUMBER OF STAFF UNDER 18 YEARS OF AGE:________________ (Must have completed an approved C
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