Fillable FAMILY CHILD CARE LICENSE/AFFILIATION APPLICATION (35th Force Support Squadron)

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FAMILY CHILD CARE LICENSE/AFFILIATION APPLICATION (35th Force Support Squadron)

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FAMILY CHILD CARE LICENSE/AFFILIATION APPLICATION
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 8013, Secretary of the Air Force: Powers and duties; delegation by E.O. 9397; implemented by DODI 6060.2 and AFPD 34-7.
PURPOSE: To record essential information on prospective Family Child Care (FCC) Providers and to be used in conjunction with background checks
ROUTINE USE: None
DISCLOSURE IS VOLUNTARY: Furnishing the information is voluntary; not providing all of the information will prevent issuing of a FCC License/Affiliation
PREVIOUS HOME ADDRESS(ES) OF LAST 2 YEARS IF DIFFERENT FROM CURRENT
APPLICANT'S NAME (LAST, FIRST, MIDDLE) FORMER SURNAME(S) SOCIAL SECURITY NUMBER (SSN) HOME PHONE
ADDRESS
CITY
ZIP CODE
CELL PHONE
STATE
SPONSOR'S SSN DUTY PHONE
SPONSOR'S NAME (LAST, FIRST, MIDDLE)
SPONSOR'S DUTY SECTION
RANK
HOUSEHOLD MEMBERS' INFORMATION - OTHER THAN APPLICANT AND SPONSOR
APPLICANT AND SPONSOR'S INFORMATION
SSNNAME (LAST, FIRST, MIDDLE) BIRTHDATE AGE RELATIONSHIP SCHOOL
ADDRESS CITY STATE
STATE
ZIP CODE
ZIP CODECITY
INSTALLATION
INSTALLATION
ADDRESS
ADDRESS
REFERENCES - PLEASE DO NOT USE RELATIVES
1 REFERENCE NAME (LAST, FIRST)
2 REFERENCE NAME (LAST, FIRST)
CITY
CITYADDRESS
ADDRESS
STATE
1 REFERENCE EMAIL ADDRESS 2 REFERENCE EMAIL ADDRESS
ZIP CODE
ZIP CODE
RELATIONSHIP
RELATIONSHIP
EDUCATION AND CHILD CARE EXPERIENCE/TRAINING
Attach a copy of your High School or General Education Development (GED) Credential
PREVIOUS EXPERIENCE - MAY ATTACH A RESUME PREVIOUS TRAINING - MAY ATTACH A RESUME
APPLICANT'S SIGNATURE
SIGNATURE OF ANY HOUSEHOLD MEMBER OVER 18 YEARS OLD
SPONSOR'S SIGNATURE
DATE
DATE
DATE
HOME PHONE HOME PHONE
STATE
We understand by signing this application, we are authorizing the United States Air Force to conduct background investigations
for initial licensing/affiliation. This may include previous installation(s) and continued licensing/affiliation on ourselves and all
household members ages 12 and up.
An Installation Records Check (IRC) on the current installation and previous installation(s), if applicable, to include: Security
Forces, Housing, Life Skills, Substance Abuse, and Family Advocacy with a check of the Air Force Central Services Registry -
Initially; annually; and when a child turns 12 years old
A Defense Central Index of Investigations (DCII) - Initially; every 5 years; and when a household member turns 18 years old
A written statement from the Sponsor's Supervisor or Commander - Initially
A statement(s) from the School Principal/Guidance Counselor for child(ren) ages 12 years and up - Initially; annually;
and when a child turns 12 years old
An IRC and DCII will be conducted on anyone, 12 years and up, who joins and remains in the household for more than 30 days
Date Received
FMP FCC 1 (REPLACES AF FORM 1928) - OCT 2006
Print Form
In accordance with Department of Defense Instruction (DODI) 1402.5, Criminal History Background on
Individuals in Child Care Services, paragraph E7.4.1, Family Child Care (FCC) Provider Applicants, all
adults, and all children 12 years and older, who reside in the household will answer the questions listed
below.
DISCLOSURE: In accordance with DODI 1402.5, paragraph E7.4.2, we understand by signing below we are signing
under penalty of perjury. In addition, a false statement rendered may result in adverse action up to and including
removal as a FCC Provider.
Household Member #1
Household Member #3
FCC Applicant's Name Spouse's Name
Household Member #1's Name Household Member #2's Name
Household Member #3's Name Household Member #4's Name
1. Have you ever been arrested for or charged with a crime involving a child?
Applicant Spouse
Household Member #1
Household Member #3
Household Member #2
Household Member #4
2. Have you ever been asked to resign because of or been decertified for a sexual offense?
Applicant
Yes
Spouse
Household Member #2
Household Member #4
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes Yes
No
No
No
No
No
No
No
Yes Yes
Yes
Yes Yes
If you answered yes to either question #1 or #2 above, please provide a description of the case disposition below. If
there is a current or past incident of illegal drug use, child abuse or domestic violence, please provide a brief
description of below:
Applicant's Signature___________________________________________________
Date___________________
Spouse's Signature____________________________________________________
#2 Household Signature________________________________________________
#3 Household Signature________________________________________________
#4 Household Signature________________________________________________
#1 Household Signature________________________________________________
Date___________________
Date___________________
Date___________________
Date___________________
Date___________________
Air Force Family Child Care License Application Continuation
Statement of Conviction
FMP FCC 9 - OCT 2006
In accordance with Air Force Instruction 34-276, Family Child Care Program, paragraph, A5.36.4, "There is no
evidence of illegal drug use, child abuse, or domestic violence current or past in the household. The provider
reports any such incidents to the FCC Coordinator." My signature below verifies there has been no current or past
illegal drug use, child abuse, or domestic violence in our household. I agree to report any such incidents or
knowledge of previous and/or future incidents to the FCC Coordinator.
Applicant's Signature___________________________________________________
Date___________________
Print Form
FMP FCC 8 – OCT 2006
Initial Health Assessment Renewal Health Assessment
FCC Applicant/Provider’s Name
In accordance with Air Force Instruction 34-276, Family Child Care Programs,
paragraph 1.10.3, providers “Are physically and mentally capable of providing care” and
paragraph A6.14.10, “The provider has a documented physical examination at least
every two years.” This “health assessment” should be related to the duties and
activities of caring for children. The following includes but is not limited to activities FCC
Providers may be required to do in order to fulfill the responsibility of a child care
provider. FCC Providers need to move quickly to supervise and assist young children;
lift children, equipment, and supplies; sit on the floor and on child-sized furniture; eat the
same food as that served to the children (unless the FCC Provider has dietary
restrictions); hear and see at a distance required for supervision or driving; be absent
from work for illness no more often than a typical adult, and be able to provide continuity
of care giving relationships for children in care. NOTE: FCC Provider must be seen
by a health care professional; a review of the FCC Provider’s medical record does
not suffice.
Date of Physical Examination ____________________
FCC Providers must be in good health in order to provide a nurturing and stable
environment for children. Based on your professional examination:
This patient is cleared to work with children.
This patient has not been cleared to work with children.
Explanation attached.
Health Care Professional’s Name/Title _______________________________________
Health Care Professional’s Signature ________________________________________
Telephone (___)_______________ Date _________________
AIR FORCE FAMILY CHILD CARE (FCC)
PROVIDER’S HEALTH ASSESSMENT
FMP FCC 10 – OCT 2006
__________________
Date
NOTE: One form for each pet.
FCC Applicant/Provider’s Name _____________________________________
Name of pet __________________ Type of pet __________________
In accordance with Caring for Our Children, Standard, 3.042, “Any pet or animal present at the
FCC Home shall be in good health, show no evidence of carrying any disease, be fully
immunized, and be maintained on a flea, tick, and worm control program. A current (time-
specified) certificate from a veterinarian shall be on file in the home, stating that the specific pet
meets these conditions.” Standard 3.043 states, “The FCC home shall not keep or bring in
ferrets, turtles, iguanas, lizards or other reptiles, psittacine birds (birds of the parrot family), or
any wild or dangerous animals.”
There is no evidence this pet is carrying any disease(s).
If applicable, this pet has been immunized against rabies.
Date rabies vaccination expires __________________
If applicable, this pet has been immunized against distemper.
Date distemper vaccination expires __________________
This pet is free of parasites and fleas.
I have examined the above named pet and certify that it meets all the conditions stated above.
This Pet Certificate expires on __________________________________
Veterinarian’s Name __________________________________________
Veterinarian’s Signature _______________________________________
Telephone (___)_______________ Date _________________
AIR FORCE FAMILY CHILD CARE (FCC)
INDIVIDUAL PET ASSESSMENT
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FAMILY CHILD CARE LICENSEAFFILIATION APPLICATION (35th Force Support Squadron)

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Completed 25 July 2021

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