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DHS-CO-202D GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HUMAN SERVICES BUREAU OF LICENSING APPLICATION FOR A VIRGIN ISLANDS LICENSE TO OPERATE AN AFTER SCHOOL PROGRAM I. Name of Facility: _______________________________________________ FOR USE BY DHS ONLY Application Date___________ Date Approved_____________ Date Denied _______________ Street Address: _______________________________________________ _______________________________________________ _______________________________________________ Telephone: ____________________________ Check Type of Facility: Church Proprietorship Public Agency Commercial Partnership Corporation II. A. (Proprietorship or Partnership ONLY) Name(s) of Proprietors or Partners: 1. Name:_________________________________________________ Telephone:______________ Last First M.I Home Mailing ______________ Address:_________________________________________________ Work Residence:_______________________________________________ 2. Name:__________________________________________________ Telephone:______________ Last First M.I Home Mailing ______________ Address:_________________________________________________ Work Residence:________________________________________________ 1 B. (Church, Commercial, Corporation, or Public Agency ONLY) Name of Church, Corporation or Public Agency: _________________________________________________ Address:________________________________________________ Telephone:______________________ Designated Representative:_________________________________ Title___________________________ Home Address:___________________________________________ Telephone:_____________________ Include Articles of Incorporation Tax Exempt Certificates By Laws Names & Address of Board Members III. (For Proprietor, Partner, or President of Corporation/Agency) 1._____________________________________ 2._____________________________________ Date of Birth Date of Birth ______________________________________ ______________________________________ Place of Birth Place of Birth _______________________________________ _______________________________________ Citizenship Citizenship ________________________________________ _______________________________________ (If Naturalized give certificate #) (If Naturalized give certificate #) ________________________________________ _______________________________________ (Visa Number if applicable) (Visa Number if applicable) ________________________________________ ________________________________________ Social Security Number Social Security Number 3. Have any of the above ever been convicted of a Crime? YES NO ______________________________________________________________ Name If yes, give date, place & the nature of offense___________________________________________________ __________________________________________________________________________________________ 2 4. Educational Background_________________________________________________________________________ Years Completed Name of School(s)_________________________________________________________________________________________ Address__________________________________________________________________________________________ IV. 1.Type of Operation Full Day Half Day Other (Specify) ________________ After-School Night-Care 2. Open From_____AM/PM to ______AM/PM Days per Week: M T W T F S S (Circle each day open) Vacation Periods in Year_________________________________________________________________________ 3. Proposed Capacity: Total Number of Children (Include own pre-school children)__________________________________ Minimum Age________________________ Maximum Age_________________________ Number of staff-full-time_______________ Part Time_____________________________ 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) $__________________ V. Attachments – Attach a Copy Of all forms, brochures, etc. to be used daily activity schedule for center floor plan of Center with all room measurements, specifying function(s) of each room. Show toilet facilities, including number of basins and commodes. Show isolation area for sickness. Give area of enclosed outdoor play space. 3 written purpose and scope of service. (Proprietorship or Partnership ONLY) – statement of ownership, including who is responsible for policy making, administration, and operation. VI. 1. Describe proposed provision for medical or health inspections. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 2. Describe plans to work cooperatively with parents to promote the growth and development of each child. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 3. Describe proposed registration policy for children. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 4 VII. Please list as references the names, mailing addresses and telephone numbers of three (3) unrelated persons who are personally acquainted with you. (Churches, Corporations, or Public Agencies list three (3) references for each Officer of the Corporation or Governing body.) _________________________________ ______________________________ ___________________ Name Mailing Address Telephone _________________________________ ______________________________ ___________________ Name Mailing Address Telephone _________________________________ _______________________________ ___________________ Name Mailing Address Telephone VIII. MEDICAL INFORMATION Name of Physician____________________________________________________________________________ Address of Physician__________________________________________________________________________ 5 TWO (2) PASSPORT SIZE PHOTOS FINGERPRINTS 1 R THUMB 2 R INDEX 3 R MIDDLE 4 L RING 5 R LITTLE 10 L LITTLE 9 L RING 8 L MIDDLE 7 L INDEX 6 L THUMB LEFT FOUR FINGERS TAKEN SIMULTANEOUSLY L. THUMB R. THUMB RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLY 6 1. I authorize the Department of Human Services of the Virgin Islands Government to make a reasonable evaluation to determine compliance with Virgin Islands Rules and Regulations for Children’s Camps/After School Programs 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 an after school 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 __________________________________________________ _________________ Signature of Applicant Date __________________________________________________ _________________ Signature of Licensing Specialist Date 7