FAMILY_CHILD_CARE_PROVIDER_APPLICATION by nuhman10

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									FAMILY CHILD CARE PROVIDER
        APPLICATION




 Family Child Care Office – Resiliency Center
        600 Thomas Avenue, Bldg 198
               Basement Level
         Fort Leavenworth, KS 66027


 LaKeeta Stevenson, FCC Director, (913)684-5129
        lakeeta.stevenson@us.army.mil
    Renee Meredith, Admin Assistant, (913)684-5117
            renee.meredith@us.army.mil
Family Child Care Provider Application




Steps to apply for the position of FAMILY CHILD CARE
PROVIDER in the Child and Youth Services program:




  I. Complete Forms 5219-R(Application), and Requests for Background
     Checks for Provider, Spouse, and any children 12 years and older living in
     the household and return these to the FCC Office prior to Orientation
     Training Classes
 II. Obtain three (3) Personal References and one (1) Military Sponsor’s
     Supervisor Reference prior to Final Certification.
III. Make appointment for Health Assessment with Community Health Nurse at
     684-6535, bring immunizations. Take Medical Record Supplemental Data
     Form with you to the appointment. Return this form to FCC Office.
IV. If you have pets, a Home Child Care Pet Certificate must be obtained on
     each pet from the Post Vet Clinic prior to certification, as well as a copy of
     current vaccinations.
 V. Complete the CYMS Provider Information Form




All forms are available at FCC Office.
Family Child Care Provider Application


                       MEDICAL RECORD – SUPPLEMENTAL MEDICAL DATA
    For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
REPORT TITLE
Health Screening for Child Development Services Staff

S: I am in good health: ____ Yes     ____ No
   My family members are in good health:    ____ Yes                                      ____ No
   Currently pregnant: ____ Yes      ____ No

O: Child care provider requirements documented by exam or record review:

         1.      Free of communicable disease                                                        ____ Yes     ____ No
         2.      TB skin test or CXR of PPD reactor
                 (required within last 12 months)                                                    ____ Yes     ____ No
         3.      MMR vaccine or measles & rubella titers                                             ____ Yes     ____ No
         4.      Able to walk, bend, stoop, sit on low chairs, stand for
                 prolonged periods of time, lift 40#                                                 ____ Yes     ____ No

Comments:


A: Cleared to work in Child Development Services                                                 ____ Yes          ____ No

     ____________ Cleared pending completion of requirements


P: Pending requirements (Check any that apply):

     ____________ Referred to immunization clinic for TB skin test

     ____________ Referred to radiology for CXR

     ____________ Referred to community health nurse for hx of pos tine/PPD which has not been
                   treated or hx of hepatitis B or C

     ____________ Referred to lab for pregnancy test

     ____________ Referred to immunization clinic for MMR

     ____________ Referred to lab for rubella/rubeola titers

     ____________ Other:


PREPARED BY: (Signature &Title)                             DEPARTMENT/SERVICE/CLINIC                     DATE


PATIENT”S IDENTIFICATION (For typed or written entries give: Name – last, first,
middle; grade; date; hospital or medical facility)                                  HISTORY/PHYSICAL       FLOW CHART
                                                                                    OTHER EXAMINATION      OTHER (Specify)
                                                                                     OR EVALUATION

                                                                                    DIAGNOSTIC STUDIES
                                                                                    TREATMENT
Family Child Care Provider Application




MEMORANDUM FOR FCC APPLICANTS



SUBJECT: Family Child Care Sponsor and Adult Family Member’s Approval


I _______________________________ understand that I must have approval of my
spouse, and any other adult family members in my household, to conduct business as
an Army Family Child Care Provider as specified in my Sponsor Program Agreement
(DA 5226-R JUL 89).




DATE __________________                           _____________________________
                                                    (FCC Provider Spouse Signature)



I/we, the undersigned spouse/adult family member of the above applicant, approve of
the applicant conducting business in my/our household as an Army Family Child Care
Provider as specified in the Sponsor/Program Agreement ((DA 5226-R. JUL 89). I/we
have been full briefed and understand the obligations involved in converting our
residence into an FCC home.



DATE __________________                           _____________________________
                                                    (FCC Provider Spouse Signature)




DATE __________________                           _____________________________
                                                    (Adult Family Member Signature)
 Family Child Care Provider Application

IMWE-LVW-MWC (608-10a)                                            Date___________________


MEMORANDUM FOR _____________________________

SUBJECT: Request for Background Clearance Check

1. AR 608-10 requires a background clearance check be conducted on all Child and Youth
   Services (CYS) Personnel who work with children and youth.
2. A Background Clearance Consent Statement is on the reverse side of this from.
3. Request a background check on the following CYS Employee / Volunteer / CYS
   Contractor/ FCC Provider / FCC Sponsor / FCC household member over age 12
   (Circle one).

  Name ___________________________________ (Last, First, MI)

  Former/Maiden Name ______________________

  SSN _____________________________                         DOB ____________________________
                                                            (Date/Month/Year)

  Place of Birth _____________________________________________
                            (City/State)

  Circle One:          Active Duty         Family Member      Retired Military       Non-Military

  Rank ____________               Branch _______________ Unit____________________________




                                              Family Child Care Services, Director

To CYS Program
From_________________________                                   Date _________________________

A check of records pertaining to above individuals disclosed the following:
( ) No record
( ) Record on file; information attached _______ Call for information _______
( ) Record on file; no unfavorable information
( ) Pending receipt of further information

                                              _____________________________________________
                                              Signature/Title

                                          FOR OFFICIAL USE ONLY
     Family Child Care Provider Application
                                 CHILD & YOUTH SERVICES
                         BACKGROUND CLEARANCE CONSENT STATEMENT

AUTHORITY: Title 10, U.S. Code 3012
PRINCIPAL PURPOSE: To provide required information necessary to complete background checks
with the agencies listed, in order to become a CYS employee, a CYS Contractor, a CYS Volunteer or a
Family Child Care (FCC) provider or provider substitute. Information will also be provided to the
same agencies on all family members, 12 years of age and older residing in an FCC home.
ROUTINE USE: Same as principal purpose.
DISCLOSURE & EFFECT: VOLUNTARY. If information is not provided employment or
certification will be denied.

___I do hereby grant permission for a background check to be performed.
___I understand that this background clearance check will be conducted on myself
___I understand that this background clearance check will be conducted on all members of my
    household 12 years of age or above (FCC only).

I understand the following checks will be done:
___1. A review of my medical records by appropriate medical personnel.
___2. A Central Registry check through Social Work Services for evidence of child abuse/neglect or
        family violence.
___3. A local records check by Provost Marshal.
___4. A Crime Records Center/DCII check by the Criminal Investigation Division.
___5. A National Agency check.
___6. A financial records check through Army Community Service. (FCC & FCC Substitute)
___7. A check with my or my sponsor’s company commander. (FCC & FCC Substitute)
___8. A check with the school counselor for family members over 12. (FCC Only)
___9. A check with the Alcohol and Drug Abuse Prevention and Control Program.
___10. A check with Ft Leavenworth Frontier Heritage Communities. (FLFHC)(FCC Only)

I understand that the personal references I have listed will be contacted.

__________________________________                           _________________________________
Applicant Signature (Provider)                               Sponsor Signature (FCC only)

__________________________________                           _________________________________
Printed Name                  Date                           Printed Name                 Date

__________________________________                           _________________________________
Other Family Member Signature (FCC only)                     Other Family Member Signature (FCC)

__________________________________                           _________________________________
Printed Name                  Date                           Printed Name                  Date


                                              FOR OFFICIAL USE ONLY
Family Child Care Provider Application

                                           REFERENCES

              Each applicant must provide three (3) personal or professional references.

Applicant name:

Address:



Phone:

E-mail:


Reference:
How long have you known this applicant? _______________________________
What is your relationship? ____________________________________________
If professional, what was the job this applicant was performing? __________________________
_____________________________________________________________________________
Would you re-hire or work with this person again? __________
Have you utilized this person for child care of observed this person with children? _________
If yes, please state your opinion about his person’s interaction with the children.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________


Would you recommend this person to be a child care provider? ______. Please explain:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________________

Any information you would like to add about this applicant?
_____________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________



Signature of Reference _____________________________ Date: _______________________

Phone number ________________________________

If Military, Unit ______________________           Commander/Supervisor ___________________
Family Child Care Provider Application


                                           REFERENCES

              Each applicant must provide three (3) personal or professional references.

Applicant name:

Address:



Phone:

E-mail:


Reference:
How long have you known this applicant? _______________________________
What is your relationship? ____________________________________________
If professional, what was the job this applicant was performing? __________________________
_____________________________________________________________________________
Would you re-hire or work with this person again? __________
Have you utilized this person for child care of observed this person with children? _________
If yes, please state your opinion about his person’s interaction with the children.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________


Would you recommend this person to be a child care provider? ______. Please explain:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________________

Any information you would like to add about this applicant?
_____________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________



Signature of Reference _____________________________ Date: _______________________

Phone number ________________________________

If Military, Unit ______________________           Commander/Supervisor ___________________
Family Child Care Provider Application

                                           REFERENCES

              Each applicant must provide three (3) personal or professional references.

Applicant name:

Address:



Phone:

E-mail:


Reference:
How long have you known this applicant? _______________________________
What is your relationship? ____________________________________________
If professional, what was the job this applicant was performing? __________________________
_____________________________________________________________________________
Would you re-hire or work with this person again? __________
Have you utilized this person for child care of observed this person with children? _________
If yes, please state your opinion about his person’s interaction with the children.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________


Would you recommend this person to be a child care provider? ______. Please explain:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________________

Any information you would like to add about this applicant?
_____________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________



Signature of Reference _____________________________ Date: _______________________

Phone number ________________________________

If Military, Unit ______________________           Commander/Supervisor ___________________
Family Child Care Provider Application

                                         REFERENCES

            Each applicant must provide a Sponsor’s Commander/Supervisor Reference.

Sponsor’s Name:

Address:



Phone:

E-mail:


Reference:
How long have you known the sponsor? _______________________________
What are the sponsor’s job requirements? __________________________
_____________________________________________________________________________
Would you re-hire or work with this person again? __________


Please describe
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________


Would you recommend this family to be a FCC Home? ___________ Please explain:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________________

Any information you would like to add about the sponsor?

_____________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________



Commander/Supervisor’s Name: ___________________________________________

Signature and Date: ___________________________________________

If Military, Unit ______________________
Family Child Care Provider Application

           Provider Information for CYMS
                         Account
                              *Please check the appropriate boxes.

Housing Area                             _________________
(If on-post)

Schooling Level                              HS - Please indicate month and year__________
                                             Bach – Please provide us with a copy of BA
                                             Masters
                                             College Years (If no degree) _______

Age Group Information                        Infants (6wks – 12mths)
                                             Pre-Toddler (12 – 18mths)
                                             Pre-Toddler (18 – 24mths)
                                             Toddler (2 – 3 years)
                                             Preschool (3 – 4 years)
                                             Kindergarten
                                             School-Age (1st – 5th)

Special Requests:                            Bilingual: _______________
                                                 *Please indicate languages spoken.
                                             Pets: _______________
                                                 *Please indicate type and breed.
                                             Smoke-Free Home
                                             Special Needs Home
                                             Wheel Chair Accessible
                                             Other: _______________
                                                 *Please indicate any other special services

Days and Hours Available:                Please check all that apply.
                                             Monday                  Opening: 0600 Closing: 1800
                                             Tuesday                 Opening: 0600 Closing: 1800
                                             Wednesday               Opening: 0600 Closing: 1800
                                             Thursday                Opening: 0600 Closing: 1800
                                             Friday                  Opening: 0600 Closing: 1800
                                             Saturday                Opening:         Closing:
                                             Sunday                  Opening:         Closing:
                                             Extended Hours ___________________________

Program Type:                                Full Day
                                             Hourly Care
                                             Extended Hours
                                             Other___________

Cell Phone Number:                       ________________________________

Email Address:                           ________________________________

								
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