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DHS-CO-202C 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 FAMILY 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 Attended: _____________________________________________________________________ School Addresses: ____________________________________________________________________ Last School Grade Completed______ Yr. Comp._____ 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____________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 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 ___________________________________ ________________________________ ___________________________________ ________________________________ ___________________________________ ________________________________ TWO (2) PASSPORT SIZE PHOTOS FINGERPRINTS 1 R THUMB 2 R INDEX 3 R MIDDLE 4 L RING 5 R LITTLE 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 Family Day Care Home in the 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 Spouse Date __________________________________________________ _________________ Signature of Licensing Specialist Date