Fillable CHILD DEVELOPMENT SERVICES (CDS) FAMILY CHILD CARE (FCC) (Army MWR)

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CHILD DEVELOPMENT SERVICES (CDS) FAMILY CHILD CARE (FCC) (Army MWR)

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The CHILD DEVELOPMENT SERVICES (CDS) FAMILY CHILD CARE (FCC) (Army MWR) form is 2 pages long and contains:

  • 1 signature
  • 32 check-boxes
  • 58 other fields

Country of origin: US
File type: PDF

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NO
ARE YOU CURRENTLY CARING FOR CHILDREN
ARE YOU WILLING TO ACCEPT CHILDREN WITHOUT REGARD TO RACE, COLOR, CREED OR NATIONAL ORIGIN
ARE YOU WILLING TO ACCEPT CHILDREN FOR HOURLY CARE
ARE YOU WILLING TO ACCEPT CHILDREN FOR NIGHT CARE
ARE YOU WILLING TO ACCEPT CHILDREN FOR EXTENDED HOURS
ARE YOU WILLING TO ACCEPT CHILDREN FOR CARE DURING HOLIDAYS
ARE YOU WILLING TO ACCEPT CHILDREN FOR CARE DURING SCHOOL VACATION
ARE YOU WILLING TO ACCEPT CHILDREN FOR CARE DURING SUMMER
ARE YOU WILLING TO ACCEPT HANDICAPPED CHILDREN
ARE YOU WILLING TO ACCEPT MILDLY ILL CHILDREN
NAME OF SPONSOR (Last, first, MI)
NAME (Last, first, MI)
NAMES FROM ALL PREVIOUS MARRIAGES
DUTY STATION TELEPHONE
TELEPHONE
SUBMIT THIS FORM TO (Address) (Include ZIP Code)
ADDRESS (Include ZIP Code)
BIRTH DATE
ORGANIZATION
MAIDEN
NUMBER OF CHILDREN DESIRED FOR CARE
UNDER 2 YEARS
Check One
YES
PLEASE ANSWER THE FOLLOWING QUESTIONS
DATA REQURIED BY THE PRIVACY ACT OF 1974
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USES:
DISCLOSURE:
Title 10, United States Code, Section 3013
Information is used by DA personnel to identify potential FCC providers and services to be provided. Provide
household information, background and references.
Information provided may be released IAW the Army's blanket routine uses contained in AR 340-21.
Disclosure of requested information is voluntary; however, if information is not provided, certification of
the candidate may be denied.
FRI
SAT
HOURS AND DAYS AVAILABLE FOR CARE
MON
TUES
FULL NAME
HOUSEHOLD INFORMATION (list all members of your household)
CHILD DEVELOPMENT SERVICES (CDS) FAMILY CHILD CARE (FCC) PROVIDER APPLICATION
For use of this form, see AR 608-10, the proponent agency is ACSIM
PROVISION OF SERVICES
WED
THURS
SUN
DA FORM 5219, JUN 2009
BIRTH DATE RELATIONSHIP
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.00.ES
TOTAL6-12 YEARS2-6 YEARS
ARE THE MEMBERS OF YOUR HOUSEHOLD IN FAVOR OF YOU BECOMING PART OF THE
SIGNATURE DATE
DO YOU HAVE INDOOR HOUSEHOLD PETS (If yes, please list)
HAVE YOU EVER BEEN ASKED TO RESIGN OR BEEN DECERTIFIED AS A CHILD CARE PROVIDER BECAUSE OF SUBSTANTIATED
ALLEGATIONS OF CHILD ABUSE OR NEGLECT. IF YES, DESCRIBE.
YES
BACKGROUND
STATEMENT OF APPLICATION
WHAT IS THE LAST GRADE YOU COMPLETED IN SCHOOL
PLEASE GIVE THE NAMES AND ADDRESSES OF THREE PERSONS (other than relatives) WHOM THE ARMY MAY CONTACT FOR REFERENCES. THEY
SHOULD KNOW YOU PERSONALLY AND BE WILLING TO CERTIFY TO YOUR CHARACTER, ABILITY, AND EXPERIENCE.
HAVE YOU HAD TRAINING OR OTHER TYPES OF EXPERIENCE WHICH WILL HELP YOU AS AN FCC PROVIDER. IF YES, DESCRIBE.
HAVE YOU OR ANY FAMILY MEMBER OR PERSON RESIDING IN THE HOME EVER BEEN CONVICTED OF ANY OFFENSE (other than
minor traffic violations) OR ARE YOU CURRENTLY UNDER CHARGES FOR ANY VIOLATION OF LAW. IF YES, DESCRIBE.
ARE YOU INVOLVED IN ANY HOME BUSINESS OPERATION, I.E., SALE OF PRODUCTS, SEWING. IF YES, DESCRIBE.
REFERENCES
FULL NAME
ADDRESS TELEPHONE
REVERSE OF DA FORM 5219, JUN 2009
FCC HOME SYSTEM
YES
HOUSEHOLD INFORMATION (list all members of your household (Cont'd))
FULL NAME BIRTH DATE RELATIONSHIP
NO
NO
YES NO
NOYES
YES
YES
NO
NO
APD LC v1.00ES
I hereby apply to have my home studied for certification by the Army as a provider of child care services at this installation's FCC System. I
understand that in order to qualify, both I and my home must meet all standards contained in AR 608-10 and all installation requirements
pertaining to the care of children. I further understand that upon my certification, the Army will refer my name to potential patrons who will then
contact me directly regarding services for their children. I will not provide child care services for any child not centrally registered in the CDS
Family Child Care System. I certify that, to the best of my knowledge and belief, all of my statements are true, correct, complete and made in
good faith.
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CHILD DEVELOPMENT SERVICES (CDS) FAMILY CHILD CARE (FCC) (Army MWR)

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Completed 2 June 2021

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