Application Packet for a Family Child Care Home Registration

Application Packet for a Family

Child Care Home Registration

Maryland State Department of Education

Division of Early Childhood Development

Office of Child Care

Resource Guide

2016

TABLE OF CONTENTS

Introduction ………………………………………………………….. 2

• What is a Family Child Care Provider?

• Is This the Career for Me?

• Government Regulations

Steps to Take to Become a Family Child Care Provider………………3

Resources………………………………………………………………5

Where to Find Forms and other Resource Information………………..5

Instructions for Completing the Application Form...…………..…….. 6

Appendix A – Regional Licensing Offices ……………………………9

Appendix B – Application Packet Checklist …………………………10

Samples of OCC Forms Needed to Apply for a Family Child Care Registration

(Actual forms may be found at

www.marylandpublicschools.org/MSDE/divisions/child_care/licensing_branch/forms)

OCC 101 - Pre-Service Training………………………………11

OCC 1204 - Medical Reports…………………………………...12

OCC 1218 - Menu Plan…………………………………………13

OCC 1229 - Substitute Form……………………………………14

OCC 1230 - Application for Family Child Care Registration…..15

OCC 1260 - Release of Information………………………….....19

OCC 1261 - Emergency Escape Plan…………………………...20

OCC 1267 - Provider Information and Plan of Operation………21

OCC 1268 - Environmental Health Survey……………………..22

OCC 1275 - Additional Adult Application (if applicable)……...23

1

INRODUCTION

WHAT IS A FAMILY CHILD CARE PROVIDER?

A family child care provider is a person who uses a residence other than the child’s home to

provide paid care, on a regular basis, for one or more children who are not related to the person. In

order to ensure a safe environment, the State of Maryland limits the number of children in a family

child care home. A provider may have a maximum of eight children, with no more than two under

the age of two. The provider’s own children under the age of six are counted within th

e group of

eight.

IS THIS THE CAREER FOR ME?

Ask yourself the following questions:

• Do I enjoy working with children?

• Am I knowledgeable about child development or willing to take classes about child

development?

• Would I like to be able to set my own hours and/or wages?

• Am I interested in running a competitive business in my own home?

• (If you are currently employed) Can I afford to lose income and/or benefits while my

business grows?

If you answered "yes" to all of these questions, then you may be a goo

d candidate for a career in

family child care.

GOVERNMENT REGULATIONS

The Maryland State Department of Education's Office of Child Care (OCC), is responsible for all

child care licensing and regulation in Maryland. OCC's goal is to make sure that safe

child care is

available to all Maryland families. OCC maintains

13 Regional Licensing Offices around

Maryland, each of which is responsible for all child care licensing activities in its geographical

area.

A list of Regional Licensing Offices may be found at Appendix A.

In Maryland, famil

y child care is regulated under the Code of Maryland Regulations COMAR

13A.15

. These regulations require a person to obtain a "certificate of registration" (which is a form

of license) before the person may operate a family child care program. Being registered means that

your program meets certain child health and safety requirements. It also makes you eligible for tax

deductions, certain food subsidies, a

nd liability insurance. These benefits make your family child

care home attractive to parents and more profitable as a business.

The COMAR 13A.15 may be

found on line at

www.marylandpublicschools.org/MSDE/divisions/child_care/regulat

2

STEPS TO TAKE TO BECOME A FAMILY CHILD CARE PROVIDER

1. Contact the OCC Regional Licensing Office in Your Area

Call the OCC

Regional Licensing Office responsible for your area to let them know that you are

interested in applying to become a registered family child care provider. That office will be

responsible

for processing your application, issuing your certificate of registration, inspecting your

program to make sure it meets regulatory requirements, and providing you with technical

assistance.

(See list of Regional Offices on page 9)

2.

Take the Family Child Care Orientation Session

If you are interested in applying to become a Family Child Care Provider, y

ou must take the

Family Child Care

Orientation session as the very first step to getting a family child care

registration.

The orientation session is largely designed to inform you about the application

process and the requirements you’ll need to meet in order to receive

a certificate of registration.

This

“on-line” interactive orientation session is available on the “Orientation” page of the MSDE,

OC

C, Licensing Branch website located at:

http://earlychildhood.marylandpublicschools.org/child

-care-providers/licensing/orientations

You will

also be required to get criminal background checks for yourself and each adult (18 years

or older) resident of your home

using any approved

Maryland Criminal Justice Information System

(CJIS) processing

location. A criminal background check includes a review of both federal (FBI)

and State records. There is a fee of $37.25, payable to CJIS, to process the criminal background

check. However, there will also be a fee to have your fingerprints taken. This fee varies in

different parts of Maryland, but the average

fingerprinting fee is typically $15-20.

3. Complete Pre

-Service Training

You will need to complete a minimum of

24 clock hours of approved training in a topic or

combination of topics related to child development (i.e., the "ages and stages' of child

ren's

developmental needs), program curriculum (i.e., planning and conducting program activities), child

health and safety (i.e., childhood illnesses, child nutrition, fire safety, etc.), the care of children

with disabilities, or provider professionalism

(i.e., running a child care business, provider-parent

relations, etc.). In addition, you must obtain skills

-based CPR and First Aid Certification suitable

for the child age

-ranges that you wish to provide care for. If you plan to provide care to children

y

ounger than 2 years old, you will also have to complete SIDS (Sudden Infant Death Syndrome)

training.

Emergency Preparedness, Medication Administration, Developmental Screening,

Americans with Disabilities Act and Supporting Breastfeeding Practices must also be taken prior to

getting

a registration. To be acceptable for family child care registration purposes, pre-service

training courses must first be approved by OCC. So before you sign up for a course, check with the

regional licensing office to make sur

e the course has been approved.

3

4. Make Sure Your Home is Safe and Properly Equipped

A safe physical environment is critically important for child care, especially if you plan to care for

young children. Examples of how you can make sure that your hom

e is "child safe" include:

• Using baby gates to restrict access to potentially hazardous areas such as stairs

• Covering electrical sockets

• Making household cleansers, medicines, tools, sharp implements, weapons, and other

harmful items inaccessible to children by placing them under lock and key

• Having operable hard-wired smoke detectors in each room where the children will nap or

rest

• Maintaining a first aid kit

Making sure your home is properly equipped for child care will be important for the proper growth

and development of the children in your program. The following are examples of equipment family

child care providers usually need:

• Cribs, playpens, cots, and/or mats for children to nap or rest on

• A variety of age-appropriate toys, games, and books

• High chairs or booster seats

• Outdoor play equipment and toys

• Strollers

5. Pass OCC, Fire Safety, and Other Required Inspections

Your home will need to be inspected by the local fire authority to make sure that it meets all

applicable fire codes. Depending o

n where the home is located, other pre-registration inspections

by the Health Department or other local government agencies may also be required.

Once

everything is in place for business, a

n OCC licensing specialist will schedule a pre-registration

inspect

ion with you to make sure your home meets family child care regulations. At this time, the

licensing specialist will review the Self

-

Assessment Guide with you, and answer any questions you

may have about operating a child care program. There are no fees for any inspections conducted by

the Regional Licensing Office. However, there may be fees for inspections by the local fire

authority, Health Department, and/or other local agencies.

After all application requirements have been met and all required inspections have been passed, the

OCC Regional Licensing Office will issue a certificate of registration to you.

All registered family day care homes are initially authorized to operate for a period of two years.

At the end of that period, a continuing (i.e., no

n-

expiring) registration may be issued that continues

in effect until it is surrendered, suspended, or revoked. A non

-expiring registration may also be

placed on conditional (i.e., probationary) status if the family day care provider does not comply

with c

ertain State requirements. If failure to comply continues, the provider's registration may be

suspended or revoked.

All registered family day care homes receive an unannounced “drop in” visit annually to determine

if child health and safety requirements

are being met.

4

Resources

As soon as you receive your certificate of registration, you are ready to open your family child care

home for business!

The following are some resources you may wish to use to help get your

business started:

• Maryland Child Care Resource Network --

A statewide network of agencies that provide

resource and referral services to parents to help them find child care and that also provide

training and support services to potential and current child care providers.

• The Family Day Care Provider Grant Program -- Administered by OCC, this program

reimburses registered providers

who meet income eligibility requirements for up to $500 in

expenditures related to achieving or maintaining compliance with family child care

regulations.

Child and Adult Care Food Program

The

Child and Adult Care Food Program is funded by the U.S. Department of Agriculture

and

administered in Maryland by MSDE's School and Community Nutrition Programs Branch.

The

program provides child care food subsidies for low-income families. Child care centers

that

participate in the program are eligible to receive reimbursement for program food costs.

Where

to find forms and other resource information.

Samples of the application and other forms needed to apply for a Family Child Care

Registration may be found in this packet on pages 11

-23.

All forms are located on our website at

http://www.marylandpublicschools.org/MSDE/divisions/child_care/licensing_branch/forms

For other resource information, you may c

lick on “Resource Documents” in the right margin.

5

Instructions for Completing

the Application for Family Child Care

Begin at SECTION II – Provider and Co-Provider Applicants

Check “First Registration Applicant” if you have never been a registered family child care

provider in Maryland, or you have previously been a registered family child care provider, but

you have been closed more than 6 months. Check the second box if you are applying to be a

“Co-provider”. A Co-provider is an individual who desires to partner with the provider to

provide child care and wants to enjoy all rights and privileges as the provider. The co-provider

must meet all qualifications as the provider. The Co-provider may care for the children in the

absence of the provider, but only at the provider’s home.

Question 1. Please list your legal name. Last name should be written first. Nicknames will not

be accepted. If you have had any other names such as former married names or names that were

legally changed, those names must be listed in the space provided directly under question 1.

Your social security number must be listed. To hold a family child care registration in Maryland,

the provider and co-provider must each have a valid social security number.

You may obtain a tax ID number, also known as an Employee Identification Number or EIN.

An EIN may be obtained through the Internal Revenue Service (IRS). Many parents claim child

care expenses on their yearly taxes. Some providers prefer to give parents their EIN instead of

their social security number.

Question 2. Please be sure to list your email address. If you do not have one, please get one as

soon as possible.

Question 3. Your address is listed here. A family child care registration may only be issued for

your residence. Your home telephone number must be listed. It may be a landline number or a

cell phone number, whichever is the most convenient way to reach you.

The Provider Only - Check whether you are a homeowner, renter, or other and the year

the property was built. If you are a renter and the property was build prior to 1978, you

must get a Lead Risk Reduction Certificate or a Lead Free Certificate from your landlord.

Question 4. If you are currently working, check “Yes” if you can receive calls at work. The

Office may need to contact you to discuss your application and to schedule the initial inspection

at the provider’s home. If you cannot receive calls at work, check “No”.

CO-PROVDERS STOP HERE AND PROCEED TO SECTIONS III AND IV.

PROVIDERS PROCEED TO QUESTION 5

Question 5. If the family child care home is located in a condominium or a residence that

requires Homeowner’s Association membership, documentation of $300,000 in child care

liability insurance must be submitted to the office. If you have a private well, check “Private”,

if not, check “Public”. Also check the type of sewage disposal. With private sewage disposal,

you have a septic tank.

6

Question 6. List all children under the age of 18 living in your home. Please make sure that you

list full legal names. Nicknames will not be accepted. If they have a social security number,

please list it in the appropriate spot as well as their date of birth. Under relationship, list their

relationship to you, such as, daughter, father, cousin, etc. Their race should also be listed.

Question 7. List all individuals 18 years old or older living in the home. List full legal names

only. Nicknames will not be accepted. If they have a social security number, please list it in the

appropriate spot as well as their date of birth. Under relationship, list their relationship to you

Examples include son, daughter, father, cousin, roommate, etc. Their race and marital status

should also be listed.

Question 8. Check “Yes” if you are currently a child/adult foster care provider, or if you are

applying to become one. “Yes” answers will require other documents from the Foster Care

Agency. The contact person is the person that oversees your case, often referred to as a

caseworker or social worker.

Question 9. Check “Yes” if you or anyone living in the family child care home has ever been

charged with any crime, received probation before judgement or received a not criminally

responsible disposition. If not, check “No”. If you check “Yes”, thoroughly explain what

happened in the space provided. Use additional paper if needed. If you answer “Yes”, you will

receive additional instructions from the Office about the court documents that must be submitted

pertaining to incident(s) that you explained. The Office strongly recommends that you discuss,

with your household members, their criminal history.

Question 10. Check “Yes” if you or any other people living in the home are awaiting trial for a

criminal charge. If not, check “No”. If you check “Yes”, thoroughly explain what happened in

the space provided. Use additional paper if needed. If you answer “Yes”, you will receive

additional instructions from the Office about the court documents that must be submitted

pertaining to the charges(s) that you explained. The Office strongly recommends that you

discuss, with your household members, their criminal history.

Question 11. Check “Yes” if you or any other people living in the home have ever been

reported for child or adult abuse or neglect. If not, check “No”. If you answer “Yes”, please

thoroughly explain what happened in the space provided. Use additional paper if needed. The

Office strongly recommends that you discuss, with your household members, their child and

adult abuse and neglect investigations.

Question 12. If you have ever been licensed or applied to become licensed, registered or

certified to provide childcare in any other county, state, or federal jurisdiction, check “Yes” , if

not check “No”. If you check “Yes”, please list when and where in the spaces provided.

Question 13. If you have ever had a license, registration, or certification to provide any type of

child care, denied, suspended or revoked, check “Yes”, if not, check “No”. If “Yes”, document

when, where and give a brief explanation. For “Yes” answers, the Office may request

documentation from the agency that denied, suspended or revoked your license, registration or

certification.

7

SECTION III – TO BE COMPLETED BY THE CO-PROVIDER ONLY

Question 1. Check “Yes” if you have ever been charged with any crime, received probation

before judgement or received a not criminally responsible disposition. If not, check “No”. If

you check “Yes”, thoroughly explain what happened in the space provided. Use additional paper

if needed. If you answer “Yes”, you will receive additional instructions from the Office about

the court documents that must be submitted pertaining to incident(s) that you explained. The

Question 2. Check “Yes” if you are awaiting trial for a criminal charge. If not, check “No”. If

you check “Yes”, thoroughly explain what happened in the space provided. Use additional paper

if needed. If you answer “Yes”, you will receive additional instructions from the Office about

the court documents that must be submitted pertaining to the charges(s) that you explained.

Question 3. Check “Yes” if you have ever been reported for child or adult abuse or neglect. If

not, check “No”. If you answer “Yes”, please thoroughly explain what happened in the space

provided. Use additional paper if needed.

Question 4. If you have ever been licensed or applied to become licensed, registered or certified

to provide childcare in any other county, state, or federal jurisdiction, check “Yes” , if not check

“No”. If you check “Yes”, please list when and where in the space provided.

Question 5. If you have ever had a license, registration, or certification to provide any type of

child care, denied, suspended or revoked, check “Yes”, if not, check “No”. If “Yes”, document

when, where and give a brief explanation. For “Yes” answers, the Office may request

documentation from the agency that denied, suspended or revoked your license, registration or

certification.

SECTION IV – TO BE COMPLETED BY PROVIDER AND CO-PROVIDER

This is the last page of the application. Please read, sign and date at the bottom of page. By

doing so, you are affirming that you have read the regulations 13A.15 Family Child Care and

that you agree to abide by those regulations.

The Office of Child Care (OCC) distributes a mailing list of family child care providers that

includes provider’s name, full address, and telephone number. Under State Government Article

10-617 H (5) Public Information, you will need to check one of the four statements listed that

best describes your mailing and referral list preferences. The referral list is a database that

parents use in locating child care. The database can be accessed through the internet at

www.mdchildcare.org or by calling Child Locate.

The mailing list includes mailing from OCC and your local resource and referral agency. OCC

and the Resource and Referral Agencies mail newsletters on important regulation changes,

information on training and any other information that may affect the provider community.

8

Appendix A

Regional Offices of Child Care

All regulatory activity is conducted through 13 regional offices throughout

Maryland. Please contact the regional office that licenses and registers child care

facilities in the county where you desire to provide child care.

Region # County Telephone #

Region 1 Anne Arundel 410-573-9522

Region 2 Baltimore City 410-554-8300

Region 3 Baltimore 410-583-6200

Region 4 Prince George’s 301-333-6900

Region 5 Montgomery 240-314-1400

Region 6 Howard 410-750-8779

Region 7 Washington

Garrett

Allegany 301-791-4585

Region 8 Caroline

Dorchester

Kent

Queen Anne’s

Talbot 410-819-5801

Region 9 Somerset

Wicomico

Worcester 410-713-3430

Region 10 Calvert

Charles

St. Mary’s 301-475-3770

Region 11 Harford

Cecil 410-569-2879

Region 12 Frederick 301-696-9766

Region 13 Carroll 410-549-6489

Licensing staff will be pleased to assist you!

Paula Johnson, Chief of the Licensing Branch may be reached via:

Email: paul[email protected] or Phone: 410-569-8071

9

APPLICATION FOR FAMILY CHILD CARE REGISTRATION CHECKLIST

The applicant must submit the following information to the Office of Child Care (OCC) before the application can be considered

complete. (Check appropriate column for each listed item.)

Submitted N/A

A. Application for Family Child Care Registration (OCC 1230)

B. Provider Information and Plan of Operation (OCC 1267)

C. Applicant’s Pre-Service Training Documents:

1. First Aid/CPR (current and appropriate for each age group approved for care)

2. Emergency and Disaster Planning

3. Medication Administration (effective Jan 1, 2016)

4. Americans with Disabilities Act (ADA) (effective Jan 1, 2016)

5. At least one of the following:

a. 24 clock hours of approved training - 4 clock hours in each of the

6 core of knowledge competencies (OCC 101)

b. 90 Clock hour course;

c. Department of Defense Modules for Child Care Providers;

d. Child Development Associate Credential (CDA)

e. Associate Degree that includes 15 semester hours of early

childhood or elementary education coursework;

f. Bachelor’s or higher degree in early childhood education, elementary

education or other discipline approved by the Office; or

g. Other coursework approved by the Office and

If planning to care for 1-4 children under the age of 2 years:

6. Sudden Infant Death Syndrome (SIDS) (taken within last 5 years)

7. Supporting Breastfeeding Practices effective Jan1, 2016) and

If planning to care for 3-4 children under the age of 2 years you must also include:

8. Three (3) semester hours or 45 clock hours of approved training

related to the care of children younger than 2 years old.

D. Substitute Form(s) (OCC 1229) (to include Additional Adult’s substitute, if applicable)

E. Additional Adult Application (OCC 1275) and documents to meet

Training Requirements: Current CPR/First Aid for children younger than 2 years

SIDS (within past 5 years)

F. Release of Information (OCC 1260)

1. Applicant and each resident 18 years old or older

2. Additional Adult

3. Substitute(s) to include Additional Adult’s substitute, if applicable)

4. Others with regular access to child care area during approved hours of operation

G. Medical Reports (OCC 1204)

1. Applicant and all residents

2. Additional Adult

H. Evidence of Compliance with Local Building and Zoning Codes (U&O Permit)

I. Evidence of Lead Safe Environment (Certificate for Pre 1978 Rental Property)

J. Homeowners Liability Insurance (if home located in area which requires Homeowner

Association Membership)

K. Private Sewage & Water Inspection Results

L. Environmental Health Survey (OCC 1268)

M. Fire Inspection Report

N. Emergency Escape Plan (OCC 1261)

O. Program Plan (Schedule of Activities)

P. Discipline Policy

Q. Menu Plan for 4 Weeks (OCC 1218)

R. Rabies Certificate(s)

S. Swimming Pool Certificate

NOTE: The applicant, residents 18 years or older, and all paid individuals ages 14 years or older, must get Criminal

Background Checks.

10

MARYLAND STATE DEPARTMENT OF EDUCATION

Division of Early Childhood Development - Office of Child Care

Party ID# _____________________

Record of Pre-service Approved Training for Family Child Care Applicants

Applicant Name:__________________________________________________

Phone ______________email: ______________________________________

Note: Prior to becoming registered, Family Child Care providers are required to complete a minimum of 4 clock hours of approved training in each of the 6 Core of Knowledge areas in addition to

other mandated training listed below. The Core of Knowledge areas are: Child Development (Child Dev), Curriculum (Curr), Heath, Safety and Nutrition (HSN), Special Needs (Spec N),

Professionalism (Prof), and Community (Comm).

Course Title

*Core of Knowledge Area(s) (Indicate

number of clock hours in the appropriate areas)

Date

Completed

Totals

(Please add course number if known.)

Child Dev

Curr

HSN

Spec

N

Prof

Comm

TOTALS

Other Pre-service Mandated Training

Course Title

Expiration Date

Date Completed

First Aid

CPR ____Adult ____Child ____ Infant

Emergency Preparedness

Medication Administration

Americans with Disabilities Act

Developmental Screening

SIDS(if planning to care for children under age 2)

Caring for Infants and Toddlers (45 clock hours) If planning to care for 3 or more children under

the age of 2.

Supporting Breastfeeding Practices

11

MARYLAND STATE DEPARTMENT OF EDUCATION

Office of Child Care

MEDICAL REPORT FOR CHILD CARE

Name of Person being evaluated: ____________________________________ Date of Birth: ___________

Name of Child Care Applicant/Provider/Facility: _________________________________________________

Address of Facility: ________________________________________________________________________

Dear Health Practitioner:

The person to be evaluated either provides (or plans to provide) child care services or lives in a home where

family child care is (or will be) given.

1) RESTRICTED OR REQUIRE SPECIAL CONDITIONS from contact with children in care due to having any

of the following:

a) Communicable disease: ___________________________________________________________

b) Chronic medical condition or physical impairment: _____________________________________

c) Vision/Hearing/Speech Disorder: ___________________________________________________

d) Nervous or Emotional Disorder: ____________________________________________________

e) Drug or Alcohol Abuse: __________________________________________________________

f) Immunization status: _____________________________________________________________

2) Tuberculosis Screening: (if needed or required by the Local Health Officer.)

Type of test: ________________ Results: ________________ Date: _________________

Answer question 3 if the person being evaluated provides (or plans to provide) child care services:

Persons who provide child care services must be able to participate fully in a program for active young children.

This includes lifting infants and young children, getting up and down from the floor, lively outdoor activities,

and moving furniture. It may also include transporting children in a motor vehicle.

3) Describe medical limitation(s) or medication(s) the person is taking, that may impair the person’s ability to perform

care-related activities, such as the ones noted above.

_________________________________________________________________________________________

___________________________________________ __________________ _______________________

Signature of Physician, CNP, RPA Date Phone Number

OCC 1204 - Revised 6/08 - All previous editions obsolete and replaces OCC 1258.

STAMP, PRINT, OR TYPE: Name and Address of Physician, Certified Nurse Practitioner, Registered Physician’s

Assistant.

12

Maryland State Department of Education

Division of Early Childhood Development – Office of Child Care

MENU PLAN

Week of ___________________________ Year __________

1

Juice may not be served when milk is the only other component served at snack.

2

MSDE recommends children over age two receive low-fat (1%) or fat-free (skim) milk.

MEAL

REQUIREMENTS

PORTION SIZES

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

Age 1-2

Age 3-5

Age 6-12

BREAKFAST

Fluid Milk

½ cup ¾ cup

2

1 cup

2

Fruit OR vegetable

¼ cup ½ cup ½ cup

Bread OR bread

alternate OR cereal

½ slice

¼ cup

½ slice

1/3

cup

1 slice

¾ cup

SNACK-Choose 2

Fluid Milk

1

½ cup ½ cup

2

1 cup

2

Fruit OR vegetable

½ cup ½ cup ¾ cup

Bread OR bread

alternate OR cereal

½ slice

¼ cup

½ slice

1/3 cup

1 slice

¾ cup

Meat or meat alternate

½ oz ½ oz 1 oz

LUNCH or SUPPER

Fluid Milk

½ cup ¾ cup

2

1 cup

2

Meat/poultry/fish OR

1 oz 1 ½ oz 2 oz

Cheese OR

1 oz 1 ½ oz 2 oz

Large egg OR

½ ¾ One

Peanut butter OR

2 tbsp 3 tbsp 4 tbsp

Dried beans & peas OR

¼ cup 3/8 cup ½ cup

Yogurt

½ cup ¾ cup 1 cup

2 different fruits OR

2 different vegetables

OR 1 fruit and 1

vegetable

¼ cup ½ cup ¾ cup

Bread OR bread

alternate, OR pasta OR

rice

½ slice

¼ cup

½ slice

¼ cup

1 slice

½ cup

13

MARYLAND STATE DEPARTMENT OF EDUCATION

Office of Child Care

SUBSTITUTE FORM

Name of Substitute: _______________________________________________________________________________

(First, Middle, Maiden, and Last)

Address: ________________________________________________________________________________________

City: _____________________________________________ State: ____________ Zip Code: _______________

Phone #: ____________________________Social Security #:______________________ Date of Birth: ____________

Relationship to the Provider (i.e. spouse, parent, child, sibling, etc.): _________________________________________

I have agreed to serve as a substitute for:

Provider’s name: __________________________________________________________________________________

Provider’s address: _________________________________________________________________________________

City: _____________________________________ State: _____________ Zip Code: _______________

YES

NO

I will receive payment for substituting. If yes, must apply for Federal and State criminal background

checks.

I am at least 18 years of age and physically and mentally capable of providing care for children.

I have read the family day care regulations and agree to follow them. (Regulation website is:

http://www.marylandpublicschools.org/MSDE/divisions/child_care/licensing_branch/regulat)

I agree to be ready to substitute at the provider’s address during the child care hours.

I understand that a substitute cannot be used as a substitute for more than 20 days in any 12-month period. A day counts only

when the substitute gives care for more than 2 hours. The Office of Child Care (OCC) must approve, in advance, the use of more

than 20 substitute days in a 12-month period.

I understand that OCC will complete a child and adult abuse and neglect check on me, which requires the completion of a

notarized release of information form. I understand that I cannot be used as a substitute until OCC completes the required

clearances for my approval.

I understand that the provider shall inform me about matters pertinent to the health and safety or welfare of children in care.

I certify that the information on this form is correct and true.

Signature: ________________________________________

Date: ____________________________________________

OCC 1229 - Revised 6/08 - All previous editions are obsolete.

14

MARYLAND STATE DEPARTMENT OF EDUCATION – Office of Child Care

APPLICATION FOR FAMILY CHILD CARE REGISTRATION

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ SECTION I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(To Be Completed By Regional Office)

OCC Region#:______ Jurisdiction: ______________ CCATS Provider ID#: ________________ 1

st

Orientation Date: _______________

__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SECTION II _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(To Be Completed By Applicant)

I am applying as a : (check one)



First Registration



Co-Provider Applicant With: ____________________________________________

Applicant Provider’s Name

____________________________________________

Provider’s Address

1. Applicant’s Name: ___________________________________________________________________________________________________

Last First Middle Maiden

If you have had any other names, please list: ______________________________________________________________________________

Social Security #: _________________________________________ Tax ID # (If applicable): __________________________________

2. Personal Identifying Data (NEEDED FOR CLEARANCE)

(a) Race (check all that apply):

 American Indian or Alaskan Native  Asian  Black or African-American

 Native Hawaiian or Pacific Islander  White  Other (specify): ___________________________

Ethnicity:

 Hispanic or Latino  Non-Hispanic or Latino

(b) Marital Status: Single Married Widowed Separated Divorced

(c) Primary Spoken Language: __________________________ (d) Date of Birth: ______________ (e) Sex: Male Female

(f) E-mail address: ____________________________________________________________________________________________________

3. Applicant’s Residence: _______________________________________________________________________ County: _________________

City: _____________________________________ State: ________________ Zip Code: ______________ Apartment #.: ____________

Development (If applicable): _________________________________________ Residence Telephone #: (________)___________________

Status: Homeowner Renter Other Year Property Built ____________ Lead Risk Reduction Certificate

Lead Free Certificate

If OTHER, please explain: ______________________________________________________________________________________________

4. If currently working, can you receive calls at work? YES NO

If YES, give your work telephone number: _________________________________________________________________________________

IF APPLYING AS CO-PROVIDER STOP HERE AND PROCEED TO SECTIONS III AND IV

OCC 1230 - Revised 7/14 - All previous editions are obsolete. Page 1 of 4

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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ SECTION II (Continued)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

5. Will the child care home be located in a condominium or residence which requires Homeowner’s Association membership?

YES NO

(NOTE: If YES, please be advised that the home will need to be covered by Homeowner’s Liability Insurance applicable to day care, pursuant to

Maryland law. After you become registered, you will be required to submit documentation of that insurance to the OCC Regional Office.)

Type of Water Supply: Private Public Type of Sewage Disposal: Private Public

6. List the names of children (under 18 years of age) living in your residence:

FULL NAME

SS # BIRTHDATE RELATIONSHIP RACE

7. List the full name of all adults (18 years of age or older) living in your residence:

FULL NAME

SS # BIRTHDATE RELATIONSHIP RACE

MARITAL

STATUS

Is any adult living in your residence an employee of the Maryland State Department of Education (MSDE)? YES NO

8. Are you a child/adult foster care provider? YES NO

Are you currently applying to become a foster care provider? YES NO If YES, complete the information below:

AGENCY

CONTACT PERSON TELEPHONE NUMBER

OCC 1230 - Revised 7/14 - All previous editions are obsolete. Page 2 of 4

16

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _SECTION II (Continued) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

9. Have you or any other persons living in your residence ever been convicted of any criminal charge, or received a probation before

judgment disposition, or received a not criminally responsible disposition? YES NO

If YES, explain: ________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

10. Are you or any other persons living in your residence awaiting trial on any criminal charge? YES NO

If YES, explain: _______________________________________________________________________________________________

___________________________________________________________________________________________________________

11. Have you or any other persons living in your residence ever been reported for child or adult abuse or neglect? YES NO

If YES, explain: _______________________________________________________________________________________________

___________________________________________________________________________________________________________

12. Have you ever been licensed, or have you applied to become licensed, registered or certified to provide child care in any other county, state, or

federal jurisdiction? YES NO If YES, state when and where: __________________________________________

__________________________________________________________________________________________________________

13. Have you ever had a license, registration or certification for any type of care denied, suspended or revoked? YES NO

If YES, document when, where, and give a brief explanation: ______________________________________________________________

__________________________________________________________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _SECTION III _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _

TO BE COMPLETED BY CO-PROVIDER ONLY

1. Have you ever been convicted or any criminal charge, or received a probation before judgment disposition, or received a not criminally

responsible disposition? YES NO

2. Are you awaiting trial on any criminal charge? YES NO

3. Have you ever been reported for child abuse or neglect? YES NO

4. Have you ever been licensed, or have you applied to become licensed, registered or certified to provide child care in any other county, state, or

federal jurisdiction? YES NO

If YES, state when and where: _____________________________________________________________________________________________

5. Have you ever had a license, registration, or certification for any type of care denied, suspended or revoked? YES NO

If YES, document when, where, and give a brief explanation: _____________________________________________________________________

_________________________________________________________________________________________________________________________

If you answered “YES” to questions 1, 2, or 3, please explain. (add additional sheets if necessary): __________________________________________

_________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

OCC 1230 - Revised 7/14 - All previous editions are obsolete. Page 3 of 4

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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ SECTION IV _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(To Be Completed by Applicant)

APPLICANT’S STATEMENT

I understand the regulations can be viewed and printed from the following website:

http://www.marylandpublicschools.org/MSDE/divisions/child_care/licensing_branch/regulat

I have read the regulations for family child care registration, COMAR 13A.14.01. If I am registered, I agree to abide by

those regulations, which include (but are not limited to) the following requirements:

a. Display the registration certificate in a conspicuous place;

b. Maintain my assigned capacity;

c. Provide supervision to the children in care at all times as required by family child care regulations;

d. Report to the appropriate authorities all suspected cases of child abuse and neglect;

e. Report to the Office of Child Care (OCC) all serious injuries and deaths involving children in my care;

f. Post emergency information;

g. Cooperate in any investigation regarding my application or registration;

h. Permit unannounced visits by the OCC;

i. Maintain all records required by the regulations;

j. Give the Consumer Education Pamphlet to each parent of a child enrolled in my care;

k. Execute a written agreement with each parent; and

l. Report to the OCC all changes which might affect the status of the registration.

The OCC distributes a mailing list of family child care providers that includes provider’s name, full address, and

telephone number. Under State Government Article § 10-617H (5) (Public Information”):

“A custodian who sells lists of licenses shall omit from the lists the name of any licensee, on written request of the

licensee.”

Please check one of the following:

Please keep my name on both the referral list and the mailing list.

Please keep my name on the mailing list, but remove it from the referral list.

Please keep my name on the referral list, but remove it from the mailing list. *

Please remove my name from both the referral list and the mailing list. *

*NOTE the following:

(1) By removing your name from the mailing list, you may lose the opportunity to receive information concerning

continued training and other mailings related to child care.

(2) By removing your name from the referral list, you may lose the opportunity to have parents referred to your program

by the Office of Child Care and local Child Care Resource and Referral Centers.

I understand that I must submit all documents required by the OCC to the Regional Office before my application can be

approved. The information I have given on this entire application form and on all other required application documents

is true, correct, and complete to the best of my knowledge.

____________________________________________________ __________________________________

Signature Date

OCC 1230 - Revised 7/14 - All previous editions are obsolete. Page 4 of 4

18

19

MARYLAND STATE DEPARTMENT OF EDUCATION

Office of Child Care

EMERGENCY ESCAPE PLAN

INSTRUCTIONS: 1. Draw a simple diagram of your entire home in the space below.

2. Name each area and room used for child care.

3. Show the use of each area (such as napping, eating, playing, off-limits, etc.).

4. Show two exits from each area (such as window or door).

5. Show a meeting place.

Emergency Escape Plan For:

Name: _________________________________________

Address: _______________________________________

_______________________________________________

Telephone Number: ______________________________

POST THIS PLAN IN THE CHILD CARE AREA.

OCC 1261 - Revised 6/08 - All previous editions are obsolete.

SAMPLE – Family Child Care Home

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MARYLAND STATE DEPARTMENT OF EDUCATION

Office of Child Care

PROVIDER INFORMATION AND PLAN OF OPERATION

Name of Applicant: ____________________________________________________________________________________

Name of Facility (if different from applicant's name): __________________________________________________________

Address: ________________________________________________________________________________________________________

City/Town: _________________________ Zip Code: ___________ Telephone #: ______________________________

1. Days of Operation:

 Monday – Friday  Saturday  Sunday

2. Hours of Operation:

 Days (6am-6pm)  Evenings (6pm-12am)

 Overnight (12am-6am) (a separate Overnight Care Plan is required)

3. Food Services:  Meals  Snacks  Meals and Snacks  None

4. Local Public Elementary School in your district: ______________________________________________________________

5. Outdoor areas on premises or near the home which will be routinely used by children in care.

(Example: back yard and patio, elementary school playground, (specify) local park (specify), etc.)

____________________________________________________________________________________________________________________

6. Identify type(s) of pet(s) in the home (i.e., dog, cat, bird, reptiles, etc.) Rabies documentation is required for all cats and dogs.

_________________________________________________________________________________________________________

7. a) Identify bodies of water on or near your property (i.e., pools, spas, streams, fish ponds, etc.)

____________________________________________________________________________________________________________________

b) Identify any body of water you plan to use for child care activities.

_________________________________________________________________________________________________________

OCC 1267 – Revised 6/08 - All previous editions are obsolete and replaces OCC 1473.

For Initial/Resumption

of

Service Registration

and Changes ONLY

21

MARYLAND STATE DEPARTMENT OF EDUCATION

Office of Child Care

ENVIRONMENTAL HEALTH SURVEY

THIS SECTION TO BE COMPLETED BY THE APPLICANT

Name of Provider/Facility:

Address of Provider/Facility:

_________________________________________________________________________________

Phone Number:

County:

Number living in Family Child Care Home: (do not include provider’s own children under 6 years of age)

Requested Capacity: (maximum number of children at any time including provider’s own children under 6 years of age)

Water Supply:

PUBLIC

PRIVATE

Sewage Disposal:

PUBLIC

PRIVATE

THIS SECTION TO BE COMPLETED BY LOCAL HEALTH DEPARTMENT

In Compliance

Not in Compliance

Recommendation:

License/Register

License/Register with plan to correct

Do not License/Register

Emergency Suspension because of imminent risk to children

Comments: ____________________________________________________________________________________________________

______________________________________________________________________________________________________________

_________________________________________ ____________ __________________________________ _________________

Health Department Inspector Signature Date Health Officer Representative Signature Date

Return completed form to: ________________________________________________________ by: ____________________________

OCC 1268 (Revised 7/05) All previous editions are obsolete.

Findings:

Water Supply:

Sewage Disposal:

22

MARYLAND STATE DEPARTMENT OF EDUCATION

Office of Child Care

ADDITIONAL ADULT APPLICATION

APPLICATION FOR APPROVAL OF THREE OR FOUR INFANTS/TODDLERS

1. Applying as an Additional Adult for:

Name of Registered Family Child Care Provider: __________________________________________

Address of Registered Home: _________________________________________ Apt. #: __________

City/Town: ____________________________ Zip Code: __________ Phone #: _________________

2. Name: ___________________________________________________________________________

Last First Middle Maiden

If you have had any other names, please list them: _________________________________________

 Female  Male Social Security #: _______________________ Date of Birth: _____________

3. Home Address: ___________________________________________________ Apt. #: ___________

City/Town: ___________________________________ State: ___________ Zip Code: ___________

Phone #: ____________________________ E-mail address: _______________________________

Mailing Address (if different from home address): _________________________________________

_________________________________________________________________________________

4. If currently working, can you receive calls at work?

 Yes  No

If Yes, give your work telephone number: _______________________________________________

5. Have you ever been convicted of any criminal charge, or are you awaiting trial on any criminal

charge?

 Yes  No If Yes, explain: ______________________________________________

__________________________________________________________________________________

OCC 1275 – Revised 10/08 – All previous editions are obsolete. Page 1 of 2

23

6. Have you ever been reported for child or adult abuse or neglect?  Yes  No

If Yes, explain: _____________________________________________________________________

__________________________________________________________________________________

7. Are you currently or have you ever been licensed, registered, or certified to provide child care in any

other county or state?

 Yes  No If Yes, give name of county and state and dates of license

or registration: ______________________________________________________________________

__________________________________________________________________________________

8. Have you ever had a license, registration or certification for any type of care denied, suspended, or

revoked?

 Yes  No If Yes, document when, where, and give a brief explanation: ________

__________________________________________________________________________________

APPLICANT’S STATEMENT

I understand that I must submit all documents required by the Office of Child Care (OCC) to the OCC Regional

Office before my application can be approved.

I understand the regulations can be viewed and printed from the following website:

http://www.marylandpublicschools.org/MSDE/divisions/child_care/licensing_branch/regulat

I have read the Family Child Care Regulations (COMAR 13A.15.01-.15). If my application to serve as an

Additional Adult is approved, I agree to abide by those regulations, which include (but are not limited to) the

following requirements.

a. To cooperate in any investigation regarding my application;

b. To report all suspected cases of child abuse and neglect to the appropriate authorities;

c. To maintain records required by the regulations;

d. To permit unannounced visits by the Office of Child Care;

e. To supervise all children in care as required by Family Child Care Regulations.

The information I have given on this entire application form and on all other required application documents is

true, correct, and complete to the best of my knowledge.

_________________________________________________ ________________________________

Signature Date

OCC 1275 – Revised 10/08 – All previous editions are obsolete.

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