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 4150 Technology Way, 3rd Floor Carson City, Nevada 89706 Phone: 775-684-4463 Fax: 775-684-4464 1010 Ruby Vista Drive Suite, 101 Elko, Nevada 89801 Phone: 775-753-1237 Fax: 775-753-1336 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. 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: ________________________________________________________ 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) ______________________________________________________________________________ Posted 1/31/2011 American LegalNet, Inc. www.FormsWorkFlow.com 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 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. 5. ALTERNATE CAREGIVER: TRAINING/CERTIFICATE TB Signs & Symptoms of Illness CPR First Aid Recognizing / Reporting Child Abuse/Neglect 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 adults: NO YES If yes, list the State, agency issuing license, type of license and license number. _________________________ __________________________________________________________________________________________________________ 6. LIST EMPLOYMENT FOR PAST FIVE YEARS PLUS ALL CHILD CARE EMPLOYMENT. EMPLOYER ADDRESS FROM TO HOURS PER WEEK MO/YR MO/YR Posted 1/31/2011 American LegalNet, Inc. www.FormsWorkFlow.com Revised 1/08 WRITTEN REFERENCES: (Attach Copies) NAME/RELATIONSHIP 7. a) b) c) d) TELEPHONE NUMBER ADDRESS FACILITY INFORMATION: FACILITY STATEMENT PROVIDED TO BUREAU: YES NO If no, explain: _________________________ ___________________________________________________________________________________________________ DAYS OF OPERATION: (Be specific.) ___________________________________________________________________________________________________ HOURS OF OPERATION: (Be specific. If 24-hour care, a separate plan of providing care is required.) ___________________________________________________________________________________________________ FOOD SERVICE PROVIDED: (Include breakfast, lunch, and dinner, number of snacks and time served.) ___________________________________________________________________________________________________ CHILD CARE FOOD PROGRAM PARTICIPANT: YES NO SACK LUNCHES: (Include storage and alternate plan if child arrives without lunch.)______________________________ DRINKING WATER FREELY AVAILABLE AT ANY TIME: YES NO If no, explain: ______________________ e) FACILITY ON PUBLIC WATER: YES NO WELL WATER: YES NO SEPTIC SYSTEM: YES NO If a well is used, what is the maximum capacity of the center (including both children and adults)? _______ If number is 25 or greater, contact the Safe Drinking Water Program at 775-687-9517 BEFORE proceeding with the application to ensure the water is from an approved water source. If number is less than 25, the following tests are required to be submitted with the application and annually: Routine domestic water analysis, Bacteriological Test, and Test for mercury and lead. If facility is on a septic system the facility, Water Pollution Control must approve the capacity. Contact Water Pollution Control at 775-687-9468. f) FIREARMS KEPT IN RESIDENCE: NO YES If yes, explain storage:___________________________________ g) PRESCRIBED MEDICATION DISPENSED: YES NO If yes, include type, method of control, storage, person dispensing:__________________________________________________________________________________________ ___________________________________________________________________________________________________ g) EMERGENCY DISASTER PLAN: Copy submitted to Bureau: h) BODIES OF WATER INCLUDING POOLS, SPAS, FOUNTAINS, STREAMS, PONDS, OTHER DECORATIVE: (Note: Any body of water added after this application must be Bureau approved before it is installed.) YES NO If yes, explain: ________________________________________________________________________ ___________________________________________________________________________________________________ i) j) ASSESSMENT PLAN SUBMITTED TO BUREAU: Yes No If no, explain: ______________________________ CURRICULUM PLAN SUBMITTED TO BUREAU: Yes No If no, explain: _____________________________ YES NO If no, explain: _______________________ 8. INSURANCE INFORMATION: (A certificate of insurance must be provided to the Bureau with a 30-day cancellation clause with the Bureau listed as the certificate holder. If using a homeowner’s policy, the certificate must have a specific endorsement for child care. Policies must cover the number of children listed on the license including before/after school age children.) LIABILITY INSURANCE: Name of company:_____________________________ Contact Person:_____________________ Telephone:________________ IF ANY TRANSPORTATION WILL BE PROVIDED, COMPLETE THE FOLLOWING SECTION: Nevada’s child restraint law requires that a child be in an approved child restraint system if he/she is less than 6 years of age and weighs 60 pounds or less. Those passengers 6 years of age or older must be in seat belts or an approved child restraint system. Transportation: To/From School Field Trips Other/Explain____________________________ VEHICLE INSURANCE: (Licensee must maintain a current list of all drivers with a copy of a current Driver’s License.) Name of company:_________________________________ (Coverage must include transportation of children in care.) Vehicle Type Posted 1/31/2011 Vehicle Year Vehicle Make Vehicle Model Vehicle License Plate No. Number of Children American LegalNet, Inc. www.FormsWorkFlow.com Revised 1/08 9. LIST ALL PETS/ANIMALS RESIDING ON THE PREMISES: NAME AGE TYPE OF ANIMAL VACCINATIONS 10. FACILITY SPACE: SIZE OF HOME: USABLE INTERIOR SQUARE FEET:______________________ (35 SQ FT PER CHILD) PLAY YARD______________________(37 ½ SQ FT PER NUMBER OF CHILDREN LISTED ON LICENSE) PLAY YARD SHADE_________________(5 SQ FT PER CHILD ON PLAY YARD) USE OF FACILITY SPACE: (Attach separate page if necessary.) PLEASE PROVIDE A DRAWING OF THE FACILITY IDENTIFYING ALL EXITS, ROOMS, FUNCTIONS AND AGES AND NUMBERS OF CHILDREN USING. IN ADDITION, LABEL DIAPERING AREAS, COMMODES, HANDWASHING SINKS, FOOD PREPARATION SINKS AND OTHER SINKS. SPACE IDENTIFIED FOR SPECIFIC USE MAY NOT BE CHANGED WITHOUT ADDITIONAL BUREAU APPROVAL INCLUDING. DIAPERING AND CHANGING AREAS, INFANT AND TODDLER NURSERY AREAS AND SINK USAGE. Posted 1/31/2011 American LegalNet, Inc. www.FormsWorkFlow.com Revised 1/08 I, __________________________________________, as _____________________________________________ __________ NAME TITLE DATE of the above named facility, understand this constitutes a request for licensure as specified in NAC 432A.200 and serves as the formal document upon which a licensure decision will be based. I agree to abide by the rules promulgated by the State of Nevada for a child care facility and do hereby state that the information provided on this application is true to the best of my knowledge and belief. I have read the Regulations and Standards pertaining to the specific type(s) of facility for which licensure is requested. I authorize release of such information as may pertain to the purpose of this application, including verification of the information supplied to the Bureau. I further understand that I am responsible for employing only those persons who qualify as defined in NRS 432A and NAC 432A. I agree to allow authorized representatives of the Bureau of Services for Child Care, upon presentation of proper identification, to enter the facility during hours of operation to review facility records and documents as necessary to ascertain compliance with the Nevada Revised Statutes and Nevada Administrative Code for child care licensing. STATE OF NEVADA COUNTY OF ______________________________ __________________________________________________________ OF _______________________________________________________________________ PRINT NAME OF AFFIANT PRINT AFFIANT ADDRESS NEVADA, BEING FIRST DULY SWORN, DEPOSES AND SAYS THAT HE/SHE HAS KNOWLEDGE OF THE FACTS AS STATED THEREIN ARE TRUE. AFFIANT____________________________________________________________________________________________________________________________ (SIGNATURE OF OWNER) ADDRESS____________________________________________________________________________________________________________________________ SUBSCRIBED AND SWORN TO BEFORE ME THIS________________DAY OF ____________________200__ NOTARY PUBLIC IN AND FOR THE COUNTY OF__________________________________________________ STATE OF NEVADA. (AFFIX NOTARY STAMP HERE) _____________________________________________________________ NAME OF NOTARY PUBLIC Persons with disabilities who require special accommodations or assistance completing this application should notify the Bureau of Services for Child Care at one of the above listed offices. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------BUREAU USE ONLY Yes No Return Date/Other APPLICATION COMPLETE FEE INCLUDED/AMOUNT: FEE CORRECT BUSINESS LICENSE FIRE INSPECTION HEALTH INSPECTION SPECIAL USE PERMIT FBI CLEARANCE Posted 1/31/2011 American LegalNet, Inc. www.FormsWorkFlow.com Revised 1/08