Fill and Sign the Functional Medicine Adult New Patient Intake Forms Amy Myers Md

Official use only: Facility #______________ Date Received _______________ ARKANSAS DEPARTMENT OF HUMAN SERVICES DIVISION OF CHILD CARE & EARLY CHILDHOOD EDUCATION APPLICATION FOR CHILD CARE LICENSE/REGISTRATON (This application will not be considered complete until all information has been provided.) Please select the type(s) of license/registration you are applying for: 1. Child Care Center 2. Licensed Child Care Family Home A. Infant (Birth to18 months) 3. Registered Child Care Family Home B. Toddler (18 to 36 months) C. Preschool (2 ½ to 5 years) D. School Age (Kindergarten & up) E. Sick Care Facility Name: ____________________________________________________________ Site Address: ____________________________________________________________ Mailing Address: ____________________________________________________________ County: _______________ Facility Phone: _______________ Facility Fax: _______________ Facility Email: _________________________________________________________________ Owner’s Name: ________________________________________________________________ *Is the facility owned by a corporation? Yes No *If facility is owned by a corporation, attach a copy of board member names, addresses, and phone numbers. In addition, a copy of articles of incorporation, which have been filed with the Arkansas Secretary of State, and any amendments, shall also be attached. Owner’s Mailing Address: ________________________________________________________ Street City State Zip Owner’s Phone: ______________________ Owner’s Cell Phone: ________________________ Tax Identification Number (if applicable): ___________________________________________ Owner’s Social Security Number (if no tax identification number available): ________________ Have you previously been licensed in Arkansas under a different tax identification or social Yes No If yes, what was the number? _______________________ security number? Have you ever been licensed to provide child care in another state? Yes No If yes, please answer the following questions: What city and state were you licensed in? ___________________________________________ When were you licensed? From ________________________ to _________________________ What was the name of your licensed facility? _________________________________________ What was your tax identification or social security number? _____________________________ Has anyone in your immediate family (blood relative; by marriage; etc.) or anyone affiliated with your facility (sharing common ownership; board member; or any other interest) ever been debarred, terminated, suspended or otherwise excluded from participation by a government unit? Yes No If yes, what is the name of the party or entity excluded? __________________ What is their relationship to you? __________________________________________________ What is the name of the center or home excluded? _____________________________________ DCC 512 R(05/10) Page 1 of 2 Date you plan to begin operation at this facility: ______________________________________ Hours of operation: Sunday Monday Open Close Open Close Tuesday Months of operation: All Jan Feb March April May Wednesday June Thursday July Aug Friday Sept Oct Saturday Nov Dec Directions to this site: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The following items must be attached to your application: 1. Diagram of the facility/building, which indicates rooms that will be used by children, and locations for hand washing and toileting. 2. Criminal record, child maltreatment, central registry, and FBI record checks on applicant. 3. Copies of fire and health department approvals, if applicable. 4. Child Care Centers Only – Name of proposed director and documentation of their qualifications. 5. Licensed/registered homes only: Name all caregivers with their ages, addresses, and phone numbers, and name all residents of the home. 6. Zoning approval. 7. Arkansas Manufactured Home Commission approval, if applicable. 8. Rates. “Under the provisions of the Child Care Licensing Act 434 of 1969, amended, I hereby make application for license/registration to operate a child care center/home. I have reviewed the minimum licensing/registration requirements and agree to comply with them.” _________________________________________ Signature of owner** _____________ Date ** A letter of authorization is also required if the person signing is anyone other than the owner. Mail completed application and attachments to your Licensing Specialist DCC512 R(05/10) Page 2 of 2