Application For A School Age Only Center License Page 3
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7FOR OFFICE USEONLY
Check/Money Order
#_____________________
APPLICATION SCHOOL AGE ONLY CENTER
PLEASE READ CAREFULLY, TYPE OR PRINT LEGIBLY
PROGRAM INFORMATION
1.
Type of License: (Check one) __Provisional __Operating-Current License Number: SAOC__________
2.
Name of School Age Only Center:___________________________________________________________________
3.
Physical Address of School Age Only Center:__________________________________________________________
(
County:_____________________
Street, City, Zip Code)
4.
Type of Structure: (Check one) __Church __School__Other________________________________________
5.
Phone/Fax Number of Center, including area code: ______-______-_______Fax Number: ______-______-_______
6.
Email Address of School Age Only Center: ___________________________________________________________
7.
Name of School Age Only Center Director:___________________________________________________________
8.
Requested Licensed Capacity of School Age Only Center:________
9.
Age Range of Children to be Served by Child Care Center: FROM: _______________ TO: _______________
( years)
(years)
10.
Hours of Operation: (Specify a.m. or p.m.) FROM: _________ TO: _________ OR __24 Hour Care
11.
Days of Operation:(Check all that apply):__
Monday__Tuesday__Wednesday__Thursday__Friday__Saturday__Sunday
12.
Preferred Mailing Address:_________________________________________________________________
(
)
P.O. Box, Street, City, State, Zip Code
13
. Child Care Subsidy (choose one): __Accept subsidy.
__Currently do not accept subsidy, but willing to in the future.
__Do not accept subsidy.
14. Will the School Age Only Center be located in a private residence? __YES __NO
IF No, continue on to Page 2 of the application.→→→→→→→→→→→→→→→→→→→→→→→→→→→
IF Yes, provide the following information for ALL persons residing at the school age only center program
address INCLUDING yourself, spouse, significant other, children, grandchildren, any other person.
LEGAL NAME
OTHER NAMES
SOCIAL SECURITY
BIRTH DATE
RELATIONSHIP TO
USED (maiden, alias)
NUMBER
Month/Day/Year
APPLICANT
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