Nevada > Statewide > Division Of Child And Family Services > Adoption
Renewal Application For Family Or Group Child Care License - Nevada
| Renewal 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 HEALTH AND HUMAN SERVICES LAS VEGAS OFFICE 4180 S. Pecos Road, Suite 150 Las Vegas, Nevada 89121 Phone: 702-486-3822 Fax: 702-486-6660 CHILD CARE LICENSING ELKO OFFICE 1010 Ruby Vista Drive Suite, 101 Elko, Nevada 89801 Phone: 775-753-1237 Fax: 775-753-1301 CARSON CITY OFFICE 727 Fairview Drive, Suite E Carson City, Nevada 89701 Phone: 775-684-4463 Fax: 775-684-4464 RENEWAL 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. Family Care Home for 5 to 6 children Group Care Home for 7 to 12 children FEE SCHEDULE $ 20.00 $60.00 AMOUNT ENCLOSED $ $ 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: ________________________________________________________ List all residents in the home: (including yourself) NAME BIRTH DATE SOCIAL SECURITY RELATIONSHIP GENDER 2. ACTION REQUESTED: Check one Renewal Application/License Change in 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: __________________ 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 Other________ ___ to ___ Director Application(s): Check all that apply Submitted for: Preschool Program Director: ______________________________________________________________________________ Other Director: (EXPLAIN) ______________________________________________________________________________ Revised 9/09 American LegalNet, Inc. www.FormsWorkFlow.com 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. 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 Child Development Course with verification attached. All persons caring for children must be at least 16 years of age.) VOLUNTEERS USED IN FACILITY:__________________________ DESCRIBE DUTIES:______________________________ CHILDREN MAY NOT BE LEFT IN THE CARE OF ANY PERSON WHO HAS NOT BEEN APPROVED/CLEARED BY THE BUREAU. AN ALTERNATE CARETAKER MUST BE AT LEAST 18 YEARS OF AGE. CHILDREN MAY NOT BE LEFT IN THE CARE OF ANY PERSON UNDER 18 YEARS OF AGE. ALTERNATE CAREGIVER NAME: TRAINING/CERTIFICATE TB Infectious Disease CPR First Aid FBI ISSUANCE DATE EXPIRATION DATE Are you or anyone listed in this application now licensed or have been previously licensed for the care of children or
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