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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: ________________________________
