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. DHS-CO-202B GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HUMAN SERVICES BUREAU OF LICENSING APPLICATION FOR A VIRGIN ISLANDS LICENSE TO OPERATE A GROUP DAY CARE HOME I. Name of Applicant: _________________________________________ FOR USE BY DHS ONLY Application Date____________ Date Approved_____________ Date Denied _______________ Date of Birth: ____________________________________________ Place of Birth ____________________________________________ Citizenship _________________________________________ (If naturalized give certificate #):________________________________ Social Security Number: ____________________________________ Mailing Address__________________________________________________________________ Residence: ______________________________________________________________________ Telephone Number: ________________________________ School(s) Attended: _______________________________________________________________ School(s) Addresses: ______________________________________________________________ Last School Grade Completed________________________ II. Name of Facility: _________________________________________________________________ Telephone Number: _________________________________ Specific Address__________________________________________________________________ Directions to Day Care Home________________________________________________________ ________________________________________________________________________________ III. Type of Care Full Day Half Day Other After-School Night-Care _________________ (Specify) Open From _____AM to ______ PM Days per Week: M T W T F S S (Circle each day open) Vacation Periods in Year____________________________________________________________ Proposed Capacity: Total Number of Children (Include own pre-school children)________________________________ Minimum Age____________________ Maximum Age___________________________ Is Day Care mother solely responsible for care of Day Care Children? YES NO Give name(s) of any assistant(s) _______________________________________________________________________________ _______________________________________________________________________________ Fees – Monthly Fee (Indicate any variations in established fee, for example, for more than one (1) child in same family.) ________________________________________________________________________________ ________________________________________________________________________________ Registration Fee (if any) $_______________ Insurance Fee (if any) $_______________ IV. CHILDREN LIVING AT HOME N A M E DATE OF BIRTH SEX SCHOOL GRADE OR OCCUPATION OTHERS IN HOUSEHOLD N A M E R E L A T I O N S H I P V. RESIDENCE Own Home Rent Total Number of Rooms__________________ Area of enclosed outdoor play space___________________________________________________ VI. GENERAL INFORMATION Length of time in community________________________________________________________ If Resident Alien, give number of Visa________________________________________________ Date and Place Visa issued__________________________________________________________ Have you ever been convicted of a crime? YES NO If so, give date, place and nature of offense_____________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ TWO (2) PASSPORT SIZE PHOTOS FINGERPRINTS 1 R THUMB 2 R INDEX 3 R MIDDLE 4 L RING 5 R LITTLE 6 L THUMB 7 L INDEX 8 L MIDDLE 9 L RING 10 L LITTLE LEFT FOUR FINGERS TAKEN SIMULTANEOUSLY L. THUMB R. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLY VIII. MEDICAL INFORMATION Name of Physician____________________________________________________________________ Address of Physician__________________________________________________________________ Attachments: Attach a copy of: All forms, brochures, etc., to be used daily activity schedule. floor plan of rooms to be used by children with room measurements. Show toilet facilities and isolation area for sickness. IX. REFERENCES Please give as references the name and mailing address of three (3) unrelated persons who are personally acquainted with you. N A M E S Mailing Addresses ___________________________________ _____________________________________ ___________________________________ _____________________________________ ___________________________________ _____________________________________ X 1. I authorize the Department of Human Services of the Virgin Islands Government to make a reasonable evaluation to determine compliance with day care standards for issuance of a license, including the right to secure reference statements, as to my ability to meet requirements and prescribed rules and regulations. 2. I am aware that to operate a Group Day care Home in the Virgin Islands without a license violates Virgin Islands law and is a misdemeanor subject to penalty of the court. 3. I also state that the information given above and such other information given in the course of the licensing study, is to the best of my knowledge true and correct. _____________________________________________________________________________________ __________________________________________________ _________________ Signature of Applicant Date I have reviewed and am in agreement with this application. __________________________________________________ _________________ Signature of Applicant Date __________________________________________________ _________________ Signature of Licensing Specialist Date