Fill and Sign the New Patient Packet Fillable and Health Questionnaire Fillable Form

DPHHS-QAD/CCL-040A (Revised 8-2006) STATE OF MONTANA DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES DIVISION OF QUALITY ASSURANCE CHANGE OF NAME / ADDRESS / AGES FOR REGISTRATION / LICENSE CERTIFICATE INFANT, FAMILY, GROUP, and CENTER DAY CARE FACILITY Director / Provider Name Phone # Facility Name PV # Date that the change is effective: Please indicate the type of change that this is: Name: Please list old name: Please list new name: Address Change / New Phone #: Please list new address* OLD Physical Address Street City State Zip Street City State Zip Street City State Zip Street City State Zip OLD Mailing Address NEW Physical Address NEW Mailing Address Directions to day care site (From the nearest major street or highway) * If you are moving to a new location you will need to complete a new floor plan, square footage form, and provide us with a copy of your Public Liability and Fire insurance showing the new address and effective date. Phone #: Old: New: Ages: Please list the ages you are now caring for: Please list the ages that you wish to care for*: *If you now want to care for infants, but you were not previously, please read “The Infant Day Care Regulations.” Hours of operation (days and hours): Old: New: 1 DAY CARE LOCATION: Is the day care located in your residence? Yes No If Yes, Please complete both the Household Member table and the Caregivers table If No, you only need to complete the Caregivers table. *If you are renting please make sure it is okay with your landlord to provide day care on the rental property. HOUSEHOLD MEMBERS *In the space provided below please include the name and birth date, of all persons presently living in the home, where day care will be provided. (Please include yourself, if you reside there) Name Date Of Birth Relationship 1 2 3 4 5 CAREGIVERS Please list the names, addresses, and phone number of all persons responsible for the direct care and supervision of children in your facility. PS# (From PS# Card) WORKS 160 Hrs/Yr NAME POSITION More Than Less Than 1 2 3 4 EDUCATION AND EXPERIENCE Elementary of High School (Check years completed) 1✔ 2 3 4 5 6 7 8 9 10 11 12 College 1 2 3 4 more than 5 Degree(s) / Did you graduate or receive GED… Yes No Describe any experience and training you have had in the care and supervision of children. Give dates, locations and names of any organizations or agencies, which you worked for: 2 In Accordance with the Montana Child Care Act, (52-2-702-714), Montana Code Annotated, I hereby request the re-issuance of a Infant, Family, Group, or Day Care Center Certificate of Registration / License on the basis of my affirmation of the following statements: Please Initial a. b. c. d. e. f. g. h. i. I have received and have read a copy of the State Regulations for Family Group Day Care Homes, Day Care Centers and Infant Care. I certify, to the best of my knowledge and belief that, I will be in compliance with the State Regulations for Family/Group Day Care Homes, Day Care Centers, and Infant Care, while children are in care. I understand that I cannot care for more children at any one time than are indicated by the Registration/License Certificate. This number includes my own children under the age of 6 years. I understand that any complaints about my registered/licensed day care facility may be investigated by a representative of the Department, without prior notification. I understand that my registered/licensed day care facility may be visited, and I will allow worker entry. If I move to another address or stop providing care to children I must notify the Department of Public Health and Human Services, Child Care Licensing Program. I understand that the name and address of my registered day care home will appear on a list which is maintained by the Department of Public Health and Human Services I will keep the necessary Insurance in force covering the total number of children I am caring for. I certify that I have adequate Public Liability and Fire Insurance for the purpose of conducting child day care. Your insurance agent must complete the “Insurance Verification Form”. If you are renting we need a copy of your landlord’s Fire Insurance and written approval from your landlord that he does not mind you providing day care services. I will provide the department with the names, addresses, phone numbers, and parents names, of each child in my care whenever requested to do so by the department. To the best of my knowledge and belief, all information I have given to the Department of Public Health and Human Services and/or its authorized agents on this form is true and correct. I will supply true and correct information requested during all subsequent contacts. ___________________________________ (Signature) _____________ (Date) TO BE COMPLETED BY A NOTARY PUBLIC: Taken, Sworn, and subscribed before me, this ___________ day of _____ _______ A.D. ________ _____________________________________ (Notary Public for the State of Montana) Residing at ____________________________ My Commission Expires _________________ 3