Fillable Child Development and Care (CDC) License Exempt Provider (Michigan)

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Child Development and Care (CDC) License Exempt Provider (Michigan)

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Child Development and Care (CDC) License Exempt Provider Application
1
What type of provider is this application for?
This application is for individuals who are applying to be enrolled by the State of Michigan as either a License
Exempt-Related or License Exempt-Unrelated child care provider. See the table below to determine which provider
type you are applying to be.
License Exempt-Related
License Exempt-Unrelated
• Provider is related to the child as a:
o Sibling (not living with the child)
o Aunt or Great Aunt
o Uncle or Great Uncle
o Grandparent or Great Grandparent
• Provider and all household members (people
18 years or older who live with the provider)
must pass a criminal history background
check.
• Provider must complete a one-time Great Start
to Quality Orientation training.
How do I apply?
Complete the application and submit it along with the required proofs to:
Mail: Child Development and Care Program
Provider Enrollment
P.O. Box 30267
Lansing, MI 48909
Fax: 517-284-7529
A list of acceptable proofs can be found at: www.michigan.gov/childcare. Proofs include:
• Proof of your age.
• Proof of your identity.
• Proof of where you currently live.
• Copy of your valid Social Security card.
Note: The name on the application and all proofs must match your current name.
Am I required to take the Great Start to Quality Orientation, and how much does it cost?
All license exempt-related and unrelated child care providers are required to take a one-time Great Start to Quality
Orientation training to receive CDC payments. To register for this $10 training, visit www.miregistry.org or call
877-614-7328 as soon as possible to contact the resource center in your area. It is NOT necessary to wait until your
application is processed before you sign up and complete the training. If you have taken this training before, you do
not need to take it again.
Revised 09.2019
MDE is an equal opportunity employer/program.
• Provider is not related to the child (as listed for related).
• Provider must provide care in the child’s home.
• Provider must pass a comprehensive background check
and participate in an annual health and safety
visit. The
provider is responsible for the cost of the background
check.
• Provider must participate in an annual health and safety
visit.
• Provider must complete a one-time Great Start to Quality
Orientation training.
Child Development and Care (CDC) License Exempt Provider Application
Revised 09.2019
MDE is an equal opportunity employer/program.
2
Instructions: This application should be completed and signed by the person who will be caring for
the child(ren).
To complete this application, you must: ☐ Send to: Child Development and Care Program
☐ Answer all applicable questions. Provider Enrollment
☐ Submit proof of your age. P.O. Box 30267
☐ Submit proof of your identity. Lansing, MI 48909
☐ Submit proof of where you currently live. or
☐ Submit a copy of your valid Social Security card. Fax: 517-284-7529
☐ Sign and date the application on page 5.
☐ Sign and date the consent and disclosure on page 9. (Unrelated only)
What happens after CDC receives my application and proofs?
Your application will be reviewed by enrollment staff to ensure that everything we have received is complete and
legible. If we do not receive a complete application, or if any of the documents we receive are not legible, we will
notify you by mail. Once we have everything we need, you will be placed in line for your phone interview. Interviews
and applications are processed in the order they are received. If we are not able to reach you when we attempt to
call you for your interview, we will leave a message with the name of the person who will be conducting your interview
and the number where you can reach them. If you have voice mail, be sure it is set up and has space for new
messages so that you do not miss our call.
IMPORTANT REMINDERS
• Please send black and white copies. Do not send originals, as they may not be returned. Snapshots taken
with a cell phone are often not clear when they are faxed.
• Once we receive your complete application and proofs, you will be placed in line for your mandatory phone
interview. We will contact you using the phone number you provided on your application. If we are unable
to complete the phone interview, your application will be denied.
• Only submit your application and proofs to the Child Development and Care program, using the address or
fax number provided on this application.
• If your application was submitted by fax, and you wish to confirm that it was received, you may call us at
866-990-3227 to confirm. Please allow at least 24 hours (not counting weekends and holidays) before you
call to follow up. If the application was mailed, allow at least one week before you call us.
• Please review your application carefully before you submit it. Be sure that you have:
o Answered all applicable questions.
o Provided a contact number for your mandatory phone interview.
o Submitted copies of your proofs.
o Signed and dated your application.
Child Development and Care (CDC) License Exempt Provider Application
Revised 09.2019
MDE is an equal opportunity employer/program.
3
SECTION A: Provider Information (License Exempt-Related/Unrelated)
Instructions: Provider, use this section to tell us about yourself.
What type of child care provider are you applying to be?
☐ I am applying to become a License Exempt-Related provider (Only complete sections A, B and C.)
☐ I am applying to become a License Exempt-Unrelated provider (Only complete section A, C and D.)
First Name
Middle Name
Last Name
Gender
Do you have a former name, maiden name or alias?
☐ No ☐ Yes If Yes, list all here:
Driver License/ID Number
Address where provider lives (Number, Street, Apt. Number)
City
State
MI
Zip Code
County
P.O. Box (only complete if you are using a P.O. Box for mail)
City
State
MI
Zip Code
County
Telephone Number (required)
Social Security Number (SSN)
Provider ID Number (if known)
Have you ever had a license or registration suspended or revoked by LARA, BCHS, or MDHHS?
☐ No ☐Yes If Yes, please explain why:
Do you receive MDHHS payment for providing Adult Home Help Services? Note: Adult home help services
cannot be provided during the same hours you are providing child care.
☐ No ☐ Yes If Yes, list the person(s) you care for:
Where do you provide child care?
☐ In my home ☐ In the child’s home ☐ I live with the child
How you are related to the child(ren)?
Have you lived outside of Michigan within the last 5 years?
☐ No ☐ Yes If Yes, please list your out of state address(es) in the area below.
(Number and Street, Apt. Number)
City
State
Zip Code
County
(Number and Street, Apt. Number)
City
State
Zip Code
County
Child Development and Care (CDC) License Exempt Provider Application
Revised 09.2019
MDE is an equal opportunity employer/program.
4
SECTION B: Household Member Information (License Exempt-Related only)
Instructions: In the section below, list all adults (people 18 years of age or older) who live with you.
Name
Former/Maiden/Alias
Date of Birth
Gender
Relationship
to You
SSN
SECTION C: Requirements, Acknowledgement, and Signature (License Exempt-Related/Unrelated)
REQUIREMENTS
I understand and agree to the following requirements to be a CDC Provider:
1. I am at least 18 years of age.
2. Neither I, nor any adult in my household (License Exempt-Related only), have been found responsible for the
neglect or abuse of children by Children’s Protective Services (CPS) or been charged/convicted of crimes
associated with money, abuse, or related to health and safety.
3. I do not have any physical, emotional, or other barriers that would prevent me from giving adequate care and
supervision to children in my care.
4. I know how and when to seek help from others, such as how to use the telephone and how to respond to
emergency situations that might arise while children are in my care.
5. I have not had any license or registration revoked or suspended by the Bureau of Community and Health Systems
(BCHS), the Michigan Department of Licensing and Regulatory Affairs (LARA), or the Michigan Department of
Health and Human Services (MDHHS).
6. I have no other jobs or other obligations that conflict or interfere with the hours that I provide child care.
7. I understand that a provider who will be providing care in the child’s home must complete a fingerprint-based
national background check through the Federal Bureau of Investigation and must submit to health and safety
visits. As the provider, I am responsible for the cost of this background check.
8. I understand that a provider who is caring for a CDC eligible child must complete Great Start to Quality Orientation
training in order to receive CDC payments. If I have not already completed this one-time required training, I should
visit www.miregistry.org or call 877-614-7328 as soon as possible to find a Great Start to Quality Orientation
training in my area.
Child Development and Care (CDC) License Exempt Provider Application
Revised 09.2019
MDE is an equal opportunity employer/program.
5
ACKNOWLEDGEMENTS
I certify that I meet the previous requirements to be a CDC provider, and I understand the following:
1. The terms and conditions of my provider enrollment may be changed without advanced notice.
2. I will not receive CDC payments for any care provided for children before my application date or more
than 30 days before I complete the Great Start to Quality Orientation training.
3. All changes in my name, address, household members, or telephone number must be reported within 10
calendar days to the Child Development and Care office at 866-990-3227. Failure to report changes may result in
termination of my enrollment.
4. I can only receive CDC payment for care provided in Michigan.
5. I must not care for more than six (6) children at the same time. Children not related to me must be cared for in the
child’s own home.
6. I must not care for more than two (2) children under 12 months of age at the same time.
7. I must give the parents/substitute parents of the children in my care unlimited access to their children while they
are in my care.
8. I must only release a child to the parent/substitute parent or persons authorized by the parent/substitute parent.
9. I must immediately report suspected child abuse or neglect to MDHHS Central Intake at 855-444-3911.
10. As a license exempt provider, I understand that I am not employed by the State of Michigan or the CDC program,
and I am not eligible for employee-related benefits, such as Worker's Compensation, healthcare, or
Unemployment Insurance.
11. As a license exempt provider receiving payment from the State of Michigan CDC program, I understand that I am
either self-employed or employed by the parent. I (or the parent) am responsible for reporting my earnings to
Federal, State, and local tax authorities in accordance with IRS rules. For IRS information, visit www.irs.gov.
12. I must use the required CDC Daily Time and Attendance Record, found at www.michigan.gov/childcare, showing
the Care Begin and Care End times for each CDC child. The parent/substitute parent must certify that these
records are accurate by initialing each day for each child to indicate the entries are correct.
I must keep these records for four (4) years.
13. I must provide my CDC Daily Time and Attendance Records, and any other requested information, when asked
by the State of Michigan.
14. I must only bill for child care services when a CDC child is physically in my care (except for child absences on a
day when the child would normally be in my care).
15. Payment for all CDC eligible children in my care is limited to 2,016 hours in a two-week (biweekly) pay period.
16. I may be prosecuted for fraud if my intentional misrepresentation causes an overpayment.
17. If I am overpaid for any reason, even if I am overpaid in error, I must repay the CDC program. If I am overpaid,
the CDC program may collect up to 20% of any future payments, which will be applied to my overpayment
balance until the overpayment has been fully repaid.
18. I understand if I violate any of the CDC program rules, I may be removed from the CDC program for six (6)
months, twelve (12) months, or a lifetime.
By signing this, I am agreeing to all terms on this application and those in the Child Development and Care Handbook
found at www.michigan.gov/childcare.
I am also indicating that the information I have provided is true and accurate to the best of my knowledge.
SIGNATURE: I HAVE READ AND UNDERSTAND ALL PARTS OF THIS FORM. (must be completed by provider)
Signature (required)
Date of signature
Make a copy of the rights and acknowledgements and keep the copy for your records.
Revised 09.2019
MDE is an equal opportunity employer/program.
6
SECTION D: Consent and Disclosure
(License Exempt-Unrelated only)
STATE OF MICHIGAN
DEPARTMENT OF EDUCATION
MICHIGAN CHILD CARE BACKGROUND CHECK
CONSENT AND DISCLOSURE
The Child Care Background Check Program is used to conduct background checks of license exempt child
care providers in Michigan. The system will be used by the Michigan Department of Education (MDE) to
receive results for license exempt - unrelated applicants.
Applicants must have a background check, including fingerprints.
Refusal to submit to this background check will result in not being eligible to receive Child Development and
Care (CDC) payments.
Part 1 – Individual Rights
a. I understand that with my written request, I will receive a copy of any records found on any of the
registries or databases.
b. I understand that if the results of any information found on any registry is not correct, it is up to me to
contact the registry to correct it.
c. I understand that if the results of the background check are not correct, or if the conviction found in the
record is one that was expunged or set aside, I may file a redetermination request with the Department
of Licensing and Regulatory Affairs (LARA).
Part 2 –Disclosure Statements (applicant disclosure)
Convictions for certain crimes, and/or being listed on certain registries, will stop you from being enrolled in the
CDC program. For more details on the crimes or registries, go to www.michigan.gov/ccbc.
List all crimes that you have been convicted of, as well as any findings of child abuse or neglect. (Attach
additional sheets if necessary).
Offense
Date of Conviction/ Finding
City
State
Part 1 – Individual Rights
Part 2 – Disclosure
Part 3 – Applicant Information
Part 4 – Reporting Requirement
Part 5 – Consent
Part 6 -- Certification
Revised 09.2019
MDE is an equal opportunity employer/program.
7
You must answer all questions completely and neatly or delays could result.
Individual Information
Social Security Number
- - Date of Birth / /
Personal Information (Legal Name)
List All Previous Names
First Name
Middle Name
Last Name
Suffix
Place of Birth (State)
Citizenship, Country of
Height __________ Hair Color _________ Gender Male ☐ Female ☐
Weight _________ Eye Color _________ Race _________
Current Address
Address
City
State/Province
Zip County
Add previous Michigan address as needed
Address
City
State/Province
Zip County
Do you have more previous Michigan addresses? Yes ☐ No ☐
Residency
No ☐
Did you live outside of Michigan within the last five years?
Yes
☐
Previous non-Michigan address (use additional paper, if applicable)
Date of Residency From To
Country
City
Address
State/Province
Zip
County
Do you have more previous non-Michigan addresses?
Yes ☐ No ☐
Phone/E-mail address
Phone Number
Email
Driver’s License or State Identification
Number
State issued
Part 3 – Applicant Information required to process a comprehensive background check.
If Yes, you must
complete previous
addresses
Revised 09.2019
MDE is an equal opportunity employer/program.
8
Part 5 – Consent to Conduct Background and Criminal Record Check (applicant consent)
To be considered for enrollment in the CDC program:
a. I consent to and give permission to MDE through the Department of Licensing and Regulatory Affairs
(LARA), to conduct a background check that includes: 1) a review of the licensing database of people
with previous disciplinary action in a child care center, group child care home, family child care home, or
an adult foster care facility; 2) a search through the national and state sex offender registries; 3) a search
through all state criminal registries for any states where I've lived in the past five years; 4) a request that
the Michigan State Police (MSP) perform a criminal history check; and 5) a search of the child abuse and
neglect registry for Michigan and any states where I've lived for the past five years.
b. I understand that refusing the background check or knowingly providing false information in
connection with a background check will result in my being found not eligible.
c. I understand that MDE will make the final decision as to whether I am enrolled in the CDC program. I
also understand that MDE may end the background check or decide to not allow me to enroll in the CDC
program at any stage in the process.
d. I agree to provide all the information necessary to conduct a background check.
Privacy Act Statement:
Authority: Acquisition, preservation, and exchange of fingerprints and associated information by the Federal
Bureau of Investigation (FBI) is generally authorized under 28 U.S.C. 534. Depending on the nature of your
application, supplemental authorities include Federal statutes, State statues pursuant to Pub. L. 92-544,
Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information
is voluntary; however, failure to do so may affect completion or approval of your application.
Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be
predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics
may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the
purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI)
system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available
records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints
and associated information/biometrics in NGI after the completion of this application and, while retained, your
fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.
Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and
associated information /biometrics are retained in NGI, your information may be disclosed pursuant to your
consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all
applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses
for the NGI system and the FBI’s Blanket Routine Uses. Routine Uses include, but are not limited to,
disclosures to: employing, governmental or authorized non-governmental agencies responsible for
employment, contracting, licensing, security clearances, and other suitability determinations; local, state tribal,
or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security
or public safety.
Continued on Next Page
Part 4 – Reporting Requirement
I understand that if I am enrolled in the program, I am required to report to CDC within 3 business days
after I have been charged or convicted of a crime that is on the crime code list, located at
www.michigan.gov/childcare in the Providers section.
Revised 09.2019
MDE is an equal opportunity employer/program.
9
Procedure to Obtain a Change, Correction, or Update of Identification Records: If, after reviewing his/her
identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wishes
changes, corrections, or updating of the alleged deficiency; he/she should make application directly to the agency
which contributed the questioned information. The subject of a record may also direct his/her challenge as to the
accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information Services (CJIS)
Division, ATTN: SCU, Mod. D2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the
challenge to the agency which submitted the data requesting that agency to verify or correct the challenged entry.
Upon the receipt of an official communication directly from the agency which contributed the original information,
the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that
agency. (28 CFR § 16.34). To challenge or correct an In State record the subject may contact the Michigan
State Police directly at (517) 241-0606 or by email at MSP-CRD-APPLHELP@michigan.gov. He/she should
provide their name, method of contact, and reason behind the challenge/correction request.
Consent: I understand that my personal information and biometric data being submitted by Live Scan, will be
used to search against identification records from both the Michigan State Police (MSP) and the FBI for the
purpose listed above. I hereby authorize the release of my personal information for such purposes and release
of any records found to the authorized requesting agency listed above.
THIS FORM MUST BE MAINTAINED IN THE PROVIDER FILE
I certify that all of the above statements are correct and complete and that failure to provide correct
information may result in being found not eligible.
Applicant's Name (Printed)
Applicant’s Signature
Date
Part 6 - Certification
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Child Development and Care (CDC) License Exempt Provider (Michigan)

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Completed 8 March 2021

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