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					                                             FAMILY DAY CARE HOME
                                            REGISTRATION APPLICATION

  NAME:
             First                                           Middle (Maiden)                                         Last

  ADDRESS:


                     City                                    County                                                  Zip Code

  DATE OF BIRTH:               /       /            SOCIAL SECURITY NUMBER:

  TELEPHONE #:                                          SUBSTITUTE NAME:

  SUBSTITUTE'S PHONE #:


                                           OTHER FAMILY / HOUSEHOLD MEMBERS

               NAME                                 FAMILY POSITION                  DATE OF BIRTH              SOCIAL SECURITY #




 Hours of Operation: From                         To                              (please specify AM or PM)

 Ages of children I will accept in my care: From                           To                      (including my own children)

 Drinking water provided by (Check One):       City of Tallahassee              Talquin Electric        Other Community Provider

                                              Private Well            **

 ** NOTE:       As per Florida Statute Chapter 381.0062 and Florida Administrative Code Chapter 64E-8, all private drinking
                water wells serving Family Day Care Homes must obtain an annual operating permit as a Limited Use
                 Commercial Water Systems and comply with all system requirements specified in Statute and Code.


 In accordance with Section 402.33 1, Florida Statutes, I hereby register this family day care home with the Leon County Health
 Department. I understand that through this registration the Health Department has the right to conduct a screening and background
 check on myself and other family members which includes, but is not limited to, character references, a criminal background check,
 abuse registry clearance. (Includes delinquency checks on house hold members between the ages of 12 and 18 years.)




Owner / Operator Signature                                                                                    Date
-




    Jeb Bush                                                                         Robert G. Brooks, M.D.
    Governor                                                                                      Secretary


    PLEASE SIGN AND RETURN THIS STATEMENT WITH YOUR
    APPLICATION.




    Pursuant to Florida Statutes 402.313(1)7, I understand that, as a Registered Family Day
    Care Home, it is my responsibility to keep current immunization records on all children in
    my care, including my own.



                                              -
    signature of owner/operator                                  date




               Leon County Health Department/Environmental Health P.O. Box 3825   Tallahassee, FL 32315
                                       PROMOTE HEALTH, PREVENT DISEASE