Government of the Virgin Islands of the United States Department of Human Services Office of Child Care & Regulatory Services Application For Child Care License Return ALL applications and supporting documentation to the island where your facility is located. CHECK TYPE OF APPLICATION: □NEW □REVISION □RENEWAL □SUMMER PROGRAM NAME: PHONE PHYSICAL LOCATION: STREET CITY/TOWN STATE ZIP CODE MAILING ADDRESS: STREET CITY/TOWN STATE ZIP CODE NAME OF APPLICANT/OWNER: MAILING ADDRESS: STREET CITY/TOWN STATE ZIP CODE APPLICANT/OWNER’S PHONE NUMBER: E-MAIL ADDRESS: SOCIAL SECURITY NUMBER (IF APPLICANT IS AN INDIVIDUAL): FEDERAL TAX I.D. NUMBER (IF ONE HAS BEEN ASSIGNED): NUMBER & AGE RANGE OF CHILDREN TO BE CARED FOR: (USE ADDITIONAL PAPER IF NECESSARY) IF YOU WANT A SINGLE LICENSE TO INCLUDE MULTIPLE BUILDINGS (CHILD CARE PROGRAMS ON THE SAME OR CONTIGUOUS PROPERTY) (RESIDENTAIL FACILITIES IN SAME GEOGRAPHICAL REGION), YOU MUST PROVIDE THE FOLLOWING FOR EACH BUILDING: 1. A MEANS BY WHICH WE CAN IDENTIFY THE BUILDING, i.e. BUILDING #1 & 2, FRONT BUILDING, BACK BUILDING OR, IF APPROPRIATE, THE NAME OF THE BUILDING; 2. THE MAXIMUM NUMBER OF CHILDREN AND AGE RANGE THAT WILL BE CARED FOR IN THE BUILDING. BUILDING IDENTIFIER MAXIMUM NUMBER OF CHILDREN AGE RANGE TO BE CARED FOR IN EACH BUILDING FROM_____YEARS_____MONTHS TO _____YEARS_____MONTHS_____ FROM_____YEARS_____MONTHS TO _____YEARS_____MONTHS_____ FROM_____YEARS_____MONTHS TO _____YEARS_____MONTHS_____ FROM_____YEARS_____MONTHS TO _____YEARS_____MONTHS_____ CHILD CARE CENTER BASED □DAY CARE CENTER □AFTER SCHOOL □SUMMER CAMP □CERTIFICATION □KIDS CLUB/SUMMER CAMP LICENSE NIGHT CARE FAMILY BASED □FAMILY DAY CARE HOME □GROUP DAY CARE HOME RESIDENTIAL CHILD CARE □GROUP HOME □OTHER FOR OFFICE USE ONLY LICENSE NUMBER □ Knud Hansen Complex Bldg. A 1303 Hospital Ground St. Thomas, VI 00802 Phone: (340)774-0930 Fax: (340)774-9702 □ 3011 Golden Rock Christiansted St. Croix, VI 00820-4355 Phone: (340)773-2323 Fax: (340)773-6121 Department of Human Services Application for Child Care License Page 2 of 5 MONTHS OF OPERATION: DAYS OF OPERATION: OPERATING HOURS: From To FEE SCHEDULE - REGISTRATION - INSURANCE: (USE ADDITIONAL PAPER IF NECESSARY) INDICATE ANY VARIATIONS IN ESTABLISHED FEE, i.e. FOR MORE THAN ONE (1) CHILD IN SAME FAMILY. MONTHLY FEE REGISTRATION FEE INSURANCE FEE RESIDENTIAL CHILD CARE PROGRAMS MUST COMPLETE THIS SECTION. CHILD CARE PROGRAMS MUST COMPLETE THIS SECTION IF THEY ARE INCORPORATED. NAME OF CORPORATION: (IF INCORPORATED) □NON PROFIT □FOR PROFIT OFFICERS OF CORPORATION: (USE ADDITIONAL PAPER IF NECESSARY) NAME TITLE/POSITION TELEPHONE NUMBER CENTER DIRECTOR – CENTER BASED PROGRAMS PROGRAM DIRECTOR – RESIDENTIAL PROGRAMS INSTRUCTIONS: □CHECK HERE AND SKIP TO THE NEXT SECTION IF THE CENTER DIRECTOR/PROGRAM DIRECTOR IS THE SAME AS ON THE PREVIOUS PAGE. THE FOLLOWING SECTION REGARDING CENTER DIRECTOR/PROGRAM DIRECTOR MUST BE COMPLETED BY ALL NEW APPLICANTS AND BY APPLICANTS FOR RENEWAL OR REVSION IF THERE HAS BEEN A NEW CENTER DIRECTOR/PROGRAM DIRECTOR SINCE THE LAST APPLICATION WAS FILED. YOU MUST ALSO SUBMIT WITH THIS APPLICATION, DOCUMENT OF EDUCATION AND EXPERIENCE AS REQUIRED BY LICENSING RULES. NAME OF CENTER DIRECTOR/PROGRAM DIRECTOR DATE OF BIRTH DATE THE ABOVE NAMED INDIVIDUAL BEGAN WORKING AS CENTER DIRECTOR/PROGRAM DIRECTOR: MONTH DAY YEAR PLEASE CIRCLE HIGHEST SCHOOL GRADE COMPLETED: 8 9 10 11 12 or GED POST SECONDARDY EDUCATION: TRANSCRIPTS MUST BE SUBMITTED WITH THIS APPLICATION FOR CENTER DIRECTORS/PROGRAM DIRECTORS, UNLESS ALREADY ON FILE AT THE DEPARTMENT OF HUMAN SERVICES. NAME OF SCHOOL MAJOR DEGREE OR CERTIFICATE ACHIEVED OR NUMBER OF CREDITS EARNED DATES ATTENDED RELATED EXPERIENCE EMPLOYER JOB TITLE DESCRIPTION OF RESPONSIBILITES, INCLUDING AGES OF CHILDREN CARED FOR DATES OF EMPLOYMENT Department of Human Services Application for Child Care License Page 3 of 5 FAMILY CHILD CARE PROVIDER DATE OF BIRTH: _________________________ IF UNDER 21 YEARS OF AGE, YOU MUST COMPLETE THE EDUCATION SECTION BELOW AND SUBMIT WITH THE APPLICATION, DOCUMENTATION OF ADDITIONAL EDUCATION AS REQUIRED BY THE DEPARTMENT OF HUMAN SERVICES (DHS) CHILD CARE PROGRAM LICENSING RULES AND REGULATIONS. NAME OF SCHOOL NAME OF COURSE(S) DEGREE OR CERTIFICATE ACHIEVED OR NUMBER OF CREDITS EARNED DATES ATTENDED ALL APPLICANTS MUST COMPLETE THIS SECTION CHILD CARE PROGRAMS LOCATED IN A HOME MUST LIST ALL HOUSEHOLD MEMBERS, REGARDLESS OF AGE OR AMOUNT OF CONTACT WITH ENROLLED CHILDREN. RESIDENTIAL CHILD CARE PROGRAMS MUST LIST ALL HOUSEHOLD MEMBERS WHO RESIDE IN THE PROGRAM, EXCEPT FOR CHILDREN ENROLLED IN THE PROGRAM, REGARDLESS OF AGE OR AMOUNT OF CONTACT WITH ENROLLED CHILDREN. OTHER INDIVIDUALS, AGE 17 AND OLDER, ALL CHILD CARE PROGRAMS AND RESIDENTIAL CHILD CARE PROGRAMS MUST LIST ANY INDIVIDUALS WHO WILL HAVE DAILY CONTACT WITH CHILDREN ENROLLED IN THE PROGRAM, OTHER THAN CHILD CARE PERSONNEL. NAME SEX RELATIONSHIP DATE OF BIRTH CRIMINAL CONVICTIONS OR CURRENT CRIMINAL CHARGES CHILD ABUSE OR NEGLECT FINDINGS OR CURRENT INVESTIGATION INSTRUCTIONS: ALL PARTICIPANTS MUST COMPLETE THIS SECTION, BY CHECKING YES OR NO AND, IF YES, PROVIDING THE REQUESTED INFORMATION. TO THE BEST OF YOUR KNOWLEDGE, AFTER QUESTIONING ALL PARTIES, ARE THERE ANY CURRENT CRIMINAL CHARGES, OR HISTORY OF CRIMINAL CONVICTIONS, OR CURRENT INVESTIGATION OR PREVIOUS FINDINGS OF CHILD ABUSE OR NEGLECT, OR ANY CURRENT INVESTIGAITONS OR PREVIOUS ADJUDICATIONS OR JUVENILE DELINQUENCY, INVOLVING ANY APPLICANT, OWNER, PROVIDER, HOUSEHOLD MEMBER, CHILD/CARE PERSONNEL, BOARD MEMBER OR ANY OTHER INDIVIDUAL WHO WILL HAVE DAILY CONTACT WITH CHILDREN? □NO (IF NO, MOVE TO THE NEXT SECTION.) □YES (IF YES, COMPLETE THE FOLLOWING SECTIONS, PROVIDING AS MUCH DETAIL AS POSSIBLE. USE ADDITIONAL PAPER IF NECESSARY) NAME AND POSITION OR AFFILIATION OF INDIVIDUAL INDICATE WHETHER THIS IS A CHARGE, ALLEGATIONS, CONVICTION, FINDING, OR CURRENT INVESTIGATION NAME & CITY OF COURT OR OFFICE IN WHICH CASE WAS HANDLED DATE OF CONVICTION OR FINDING Department of Human Services Application for Child Care License Page 4 of 5 REFERENCES: NEW APPLICANTS ONLY (USE ADDITIONAL PAPER IF NECESSARY) NAME ADDRESS PHONE EMAIL (HOME) (CELL) (HOME) (CELL) (HOME) (CELL) (HOME) (CELL) (HOME) (CELL) PLEASE CAREFULLY READ EACH STATEMENT BEFORE SIGNING. ANY APPLICATION WHICH IS NOT COMPLETED AND SIGNED AS REQUIRED, OR WHICH IS MISSING ANY OF THE ATTACHMENTS REQUIRED BY THE (DHS) CHILD CARE PROGRAM LICENSING RULES AND REGULATIONS, WILL NOT BE ACCEPTED AS A COMPLETE APPLICATION AND WILL BE RETURNED TO THE APPLICANT FOR COMPLETION. APPLICANTS FOR LICENSE RENEWAL MUST, IN ADDTION TO THE SIGNATURE BELOW, COMPLETE AND SIGN THE FOLLOWING: I CERTIFY THAT I HAVE READ THE RULES APPLICABLE TO THE PROGRAMS FOR WHICH I AM SEEKING A LICENSE (DHS’ CHILD CARE PROGRAMS AND RESIDENTIAL CHILD CARE PROGRAMS), AND THAT THE CHILD CARE PROGRAM/RESIDENTIAL CHILD CARE PROGRAM NAMED ON THIS APPILCATION IS IN COMPLIANCE WITH ALL CRITICAL RULES. ____________________________________________________________________________ ____________________________ SIGNATURE OF APPLICANT/LICENSEE DATE SIGNED BY SIGNING BELOW, I HEREBY CERTIFY THAT: I UNDERSTAND THAT THE DEPARTMENT OF HUMAN SERVICES MAY INVESTIGATE ANY CRIMINAL CONVICTION RECORDS, FINDING OF CHILD ABUSE OR NEGLECT, OR INVESTIGATION OF OR FINAL DETERMINATION REGARDING ANY JUVENILE DELINQUENCY AND WILL MAKE A DETERMINATION REGARDING WHETHER THE INVIDIVUAL POSES A CURRENT RISK TO THE HEALTH, SAFETY OR WELL BEING OF CHILDREN; I UNDERSTAND THAT THE DEPARTMENT OF HUMAN SERVICES MAY DELAY ITS DECISION TO APPROVE OR DENY THIS APPLICATION PENDING THE OUTCOME OF ANY INVESTIGATION, WHEN THE APPLICANT, OWNER, FAMILY CHILD CARE PROVIDER, CENTER DIRECTOR, OR PROGRAM DIRECTOR ARE NAMED AS THE PERPETRATOR IN ANY CURRENT INVESTIGATION OF ANY CRIME, OR IN AN ALLEGATION OF ABUSE OR NEGLECT; I UNDERSTAND THAT PROVIDING FALSE INFORMATION ON THIS APPLICATION OR ANY OF THE ATTACHMENTS, OR FAILING TO DISCLOSE ANY INFORMATION REQUIRED ON THE APPLICATION, OR REQUIRED TO BE SUMBITTED WITH THIS APPLICATION, SHALL BE CONSIDERED GROUNDS FOR LICENSE DENIAL OR REVOCATION; I HAVE RECEIVED, AND READ THE DEPARTMENT OF HUMAN SERVICES CHILD CARE PROGRAM LICENSING RULES AND REGULATIONS, AND UNDERSTAND THAT FAILURE TO MAINTAIN MY PROGRAM IN COMPLIANCE WITH THE APPLICABLE RULES, MAY JEOPARDIZE MY LICENSE/CERTIFICATION AND/OR RESULT IN FINES BEING ASSESSED BY THE DEPARTMENT OF HUMAN SERVICES; I AUTHORIZE ANY POLICE DEPARTMENT, COURT SYSTEM OR HUMAN SERVICE AGENCY IN THIS OR ANY OTHER JURISDICITON TO RELEASE COPIES OF ANY CRIMINAL RECORDS OR CHILD ABUSE OR NEGLECT RECORDS TO THE DEPARTMENT OF HUMAN SERVICES; AND, ALL INFORMATION PROVIDED AS PART OF THIS APPLICATION AND IN THE REQUIRED ATTACHMENTS IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. ____________________________________________________________________________ ____________________________ SIGNATURE OF APPLICANT DATE SIGNED ____________________________________________________________________________ ____________________________ Department of Human Services Application for Child Care License Page 5 of 5 SIGNATURE OF CENTER DIRECTOR/PROGRAM DIRECTOR DATE SIGNED INDOOR & OUTDOOR CHILD CARE SPACE INSTRUCTIONS: COMPLETE THIS SECTION IF YOU ARE A NEW APPLICANT OR YOU ARE AN APPLICANT FOR RENEWAL OR REVISION AND THERE HAVE BEEN CHANGES TO CHILD CARE SPACE. YOU MUST COMPLETE A SEPARATE PLAN FOR EACH BUILDING WHEN THERE ARE MULTIPLE BUILDINGS. (YOU MAY COPY THIS PAGE, OR ATTACH SEPARATE SHEETS FOR EACH BUILDING.) THE PLAN MUST IDENTIFY: (ATTACH FLOOR PLAN) A. FOR INDOOR SPACE: FOR EACH BUILDING THAT WILL BE USED AS CHILD CARE SPACE, THE FLOOR PLAN SHALL INCLUDE: 1. ROOM DIMENSIONS; 2. LOCATION OF EXITS; 3. HOW EACH ROOM WILL BE USED; 4. THE LOCATION OF BATHROOMS AND BATHROOM FIXTURES (TOILETS & SINKS); AND, 5. THE LOCATION OF OTHER HAND WASHING SINKS. B. FOR OUTDOOR PLAY SPACE: 1. THE OVERALL DIMENSIONS OF OUTDOOR PLAY SPACE; 2. THE LOCATION OF EXITS, GATES, AND STATIONARY PLAY EQUIPMENT; 3. THE LOCATION OF THE OUTDOOR PLAY SPACE IN RELATIONS TO THE INDOOR SPACE; AND, 4. THE PRESENCE OF, AND LOCATION OF ANY POOLS, PONDS, STREAMS, RIVERS, OCEANS, STREETS, ROADS OR OTHER HAZARDS THAT ARE IN CLOSE PROXIMITY. □APPLICANTS FOR RENEWAL OR REVISION MUST CHECK HERE IF THERE HAVE BEEN NO CHANGES TO CHILD CARE SPACE. DIRECTIONS TO FACILITY Department of Human Services Application for Child Care License Page 6 of 5 Revised May 2010