Initial Application For Assessment For A Two Component Star Rated License Form - North Carolina Department Of Health And Human Services Page 2
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2INITIAL APPLICATION FOR ASSESSMENT FOR A TWO COMPONENT STAR RATED LICENSE
Facility Name__________________________________________________________ Facility Id#____________________________
PART I Education Standards (Rule .2817)
Fill in all information that applies to you:
Number of years/months of full-time Early Childhood Work
Indicate # of Years:_______ Months:_______
Experience (in a licensed child care center or licensed home)
Number of Training Hours taken in the last 12 months
Indicate # of clock hours: ______________
(workshops, community college classes or conferences)
Has NC Family Child Care Credential or equivalency (submit
Yes, indicate date completed:
copies of certificates)
Has completed semester hours in Early Childhood
Indicate # of semester hours:
Education/Child Development
Date my ORIGINAL College Transcripts were mailed to the
Date: ___________
Education Workforce Unit at DCDEE (attach to NC DCDEE Child
Care Providers Education & Equivalency Form)
Part II Program Standards (Rule .2828):
Check all that apply to your Family Child Care Home:
I have enclosed a copy of my Operational Policies
I would like to have the Family Child Care Environment Rating Scale – Revised (FCCERS-R) completed
I enroll no more than 4 children under age one
I enroll no more than 3 children under age one
Part III Quality Point (Rule .2829):
Indicate the quality point option(s) your facility meets:
Education Options:
____Has obtained an Infant/Toddler Care Certificate
____Has a BS/BA or higher in Early Childhood/Child Development
____Has completed 20 in-service training hours in addition to required annual hours
Program Options:
____Uses an age/developmentally appropriate Curriculum (Curriculum Name :_____________________)
____Has completed a Business training course (Name/Date of course :__________________________)
____Reduced enrollment to no more than four preschool age children
____Serves no more than two infants under age one
I certify that I have given true, accurate and complete information on this form, and all accompanying documents, to the best of my
knowledge.
______________________________
_____________
Operator Signature
Date Completed
DCDEE USE ONLY
Date Received_____________________________________________ Consultant Signature______________________
Current Compliance History score from ______________ to _____________ is ____________%
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