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RESIDENTIAL DAYCARE APPLICATION
Applicant's Name:
Mailing Address:
City  State    Zip
Phone:      Fax: 		PROPOSED EFFECTIVE DATE:
From     To

Email:
 DBA     Years in Business
 

 Form of Business: Individual   Partnership   Corporation   Non-Profit Organization 
 
 
Eligible
Not Eligible*
Prohibited
Is the Daycare located in a private residence?
Yes
No
 
Are there 10 or fewer children?
Yes
No
 
Is the daycare licensed by the state?
Yes
 
No
No claims in the last 5 years?
Yes
No
 
No more than 6 field trips and none to swimming pools?
Yes
No
 
No swimming pools on premises
Yes
No
 
No Dogs, Cats or Exotic Pets?
Yes
No
 
No business operations other than daycare services
Yes
No
 
No serving handicapped, retarded children or children with special needs?
Yes
No
 
No employed or contracted physicians or nurses?
Yes
No
 
No Babysitting or Nanny Services or Referral Agencies?
Yes
 
No
No overnight care?
Yes
 
No
Your certificate or license has never been suspended or revoked?
Yes
 
No
No alleged or actual incidents regarding child molestation or abuse?
Yes
 
No
Are background checks done on all potential employees?
Yes
No
 
No trampolines, gymnastics equipment, wall climbing equipment?
Yes
No
 
Daycare is not open more than 14 hours per day?
Yes
 
No
Daycare does not accept children to be dropped off that are not enrolled in the program?
Yes
No
 
*Not eligible for this quote.  Complete Commercial/Residential Childcare Application
 

 
 

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