Da Form 5219 PDF Details

The DA Form 5219, known as the "Child Development Services (CDS) Family Child Care (FCC) Provider Application," plays an integral role in ensuring the provision of reliable and safe childcare services within military installations. Created by the Army, this form serves as the first step for individuals aspiring to become certified Family Child Care providers, marking the onset of a rigorous vetting process. In adherence to AR 608-10, it is meticulously designed to collect comprehensive data essential for evaluating a candidate's suitability. This includes personal information, willingness to serve children of diverse backgrounds, availability for care at various times, and specific questions aimed at assessing the applicant's commitment towards offering inclusive and equitable care. Furthermore, it seeks details on the household's readiness to support the FCC home system, the applicant's educational background, experience, and any history of criminal convictions or allegations related to child abuse or neglect. Additionally, the form requires candidates to provide non-relative references to vouch for their character and capability in childcare. The thoroughness of the DA Form 5219 underscores the Army's commitment to safeguarding the well-being of children under its care, ensuring that only the most qualified individuals are entrusted with this critical responsibility.

QuestionAnswer
Form NameDa Form 5219
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesREQURIED, 2009, FCC, da form 5219

Form Preview Example

CHILD DEVELOPMENT SERVICES (CDS) FAMILY CHILD CARE (FCC) PROVIDER APPLICATION

For use of this form, see AR 608-10, the proponent agency is ACSIM

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.

 

 

NAME (Last, first, MI)

 

 

 

 

 

MAIDEN

 

 

 

NAMES FROM ALL PREVIOUS MARRIAGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS (Include ZIP Code)

 

 

 

 

 

BIRTH DATE

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF SPONSOR (Last, first, MI)

 

 

 

ORGANIZATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DUTY STATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBMIT THIS FORM TO (Address) (Include ZIP Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVISION OF SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOURS AND DAYS AVAILABLE FOR CARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MON

 

WED

 

 

FRI

 

 

 

 

SUN

 

 

 

 

 

 

 

 

 

 

 

TUES

THURS

 

 

SAT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBER OF CHILDREN DESIRED FOR CARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNDER 2 YEARS

 

 

 

 

2-6 YEARS

 

 

 

6-12 YEARS

TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE ANSWER THE FOLLOWING QUESTIONS

 

 

 

 

 

 

 

 

 

 

 

 

Check One

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOUSEHOLD INFORMATION (list all members of your household)

FULL NAME

BIRTH DATE

RELATIONSHIP

DA FORM 5219, JUN 2009

PREVIOUS EDITIONS ARE OBSOLETE.

APD PE v1.00.ES

HOUSEHOLD INFORMATION (list all members of your household (Cont'd))

FULL NAME

BIRTH DATE

RELATIONSHIP

ARE THE MEMBERS OF YOUR HOUSEHOLD IN FAVOR OF YOU BECOMING PART OF THE

FCC HOME SYSTEM

YES

DO YOU HAVE INDOOR HOUSEHOLD PETS (If yes, please list)

NO

YES

NO

BACKGROUND

WHAT IS THE LAST GRADE YOU COMPLETED IN SCHOOL

HAVE YOU HAD TRAINING OR OTHER TYPES OF EXPERIENCE WHICH WILL HELP YOU AS AN FCC PROVIDER. IF YES, DESCRIBE.

YES

NO

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

NO

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.

YES

NO

ARE YOU INVOLVED IN ANY HOME BUSINESS OPERATION, I.E., SALE OF PRODUCTS, SEWING. IF YES, DESCRIBE.

YES

NO

REFERENCES

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.

FULL NAME

ADDRESS

TELEPHONE

STATEMENT OF APPLICATION

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.

SIGNATURE

DATE

REVERSE OF DA FORM 5219, JUN 2009

APD PE v1.00ES

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Tips on how to fill in ACSIM step 1

2. The third part is to fill out these fields: ARE YOU WILLING TO ACCEPT CHILDREN, ARE YOU WILLING TO ACCEPT CHILDREN, ARE YOU WILLING TO ACCEPT CHILDREN, ARE YOU WILLING TO ACCEPT CHILDREN, ARE YOU WILLING TO ACCEPT, ARE YOU WILLING TO ACCEPT MILDLY, HOUSEHOLD INFORMATION list all, FULL NAME, BIRTH DATE, RELATIONSHIP, DA FORM JUN, PREVIOUS EDITIONS ARE OBSOLETE, and APD PE vES.

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3. Completing FULL NAME, BIRTH DATE, RELATIONSHIP, ARE THE MEMBERS OF YOUR HOUSEHOLD, FCC HOME SYSTEM, YES, DO YOU HAVE INDOOR HOUSEHOLD PETS, YES, WHAT IS THE LAST GRADE YOU, BACKGROUND, HAVE YOU HAD TRAINING OR OTHER, YES, HAVE YOU EVER BEEN ASKED TO RESIGN, YES, and HAVE YOU OR ANY FAMILY MEMBER OR is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Part # 3 of filling out ACSIM

4. The subsequent part requires your information in the subsequent parts: ARE YOU INVOLVED IN ANY HOME, YES, PLEASE GIVE THE NAMES AND, other than relatives WHOM THE ARMY, FULL NAME, ADDRESS, TELEPHONE, REFERENCES, STATEMENT OF APPLICATION, I hereby apply to have my home, understand that in order to, pertaining to the care of children, contact me directly regarding, and Family Child Care System I certify. Make sure you give all required information to move forward.

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