Dss Form 2902 – Fill Out and Use This PDF

South Carolina Department of Social Services

Child Care Licensing

APPLICATION TO OPERATE A CHILD CARE FACILITY

I CERTIFY that I understand that I am prohibited by law from applying for a child care license or registration if I have been convicted of a crime listed in the South Carolina Code of Laws, Chapter 3 of Title 16 (OffensesAgainst the Person), the crime of contributing to the delinquency of a minor (contained in Section 16-17-490), the felonies classified in Section 16-1-10(A), the offenses enumerated in Section 16-1-10(D), or a criminal offense similar in nature to the crimes listed above in other jurisdictions or under federal law. Aperson who has been convicted of a crime enumerated in Subsection A of South Carolina Code Section 63-13-40 who applies for employment with, is employed by, or seeks to provide caregiver services in, or is a caregiver at such facility is guilty of a misdemeanoranduponconvictionmustbefinednotmorethanfivethousanddollarsorimprisonednotmorethan one year, or both.

I have read the information above. Initial:

Date:

Section 1A: Provider Information (All questions must be completed by the facility.)

Name of Facility:

Name of Owner:

Name of Director:

Facility FEIN No. OR Owner’s Social Security No.:

Facility Street Address:

County/City/State/Zip:

Mailing Address: (If different)

County/City/State/Zip:

Billing Address: (If different)

County/City/State/Zip:

Telephone:

Fax:

E-Mail:

Days of Operation: (Check all that apply)

n M n Tu

n W

n Th

n F

n Sa

n Su

Hours of Operation:

Provide Overnight Care? (Care provided anytime between 1:00 AM and 5:00 AM) n Yes n No

Type of Facility Applying for: n Child Care Center (13 or more children)

n Faith-Based Child Care Center (13 or more children)

n Group Child Care Home (7-12 children)

n Family Child Care Home (Up to 6 children)

Section 1B: This section to be completed by the facility.

1. Would you like to be provided information about theABC Child Care Program? n Yes

n No

n Already Participating

If already participating, check ABC Level: n AA

n A

n BB

n B

n CC

n C

2. Would you like to be provided information about the USDA Food Program? n Yes

n No

n Already Participating

3. Please check the method by which meals will be provided.

n Prepared at Kitchen in Facility

n Prepared at a Central Kitchen

n Provide Snack Only

n Provided by Local School System n Prepared by a Food Service Company

n Do Not Prepare or Serve Food

4. Have your facility policies been updated or revised since your last renewal? n Yes

n No

If your facility policies are available online, list website address here:

If your policies have changed and are not available online, please mail a copy with this application. Registered Family Child Care Providers do not need to send in policies.

(Complete back of form)

DSS Form 2902 (NOV 11) Edition of MAY 11 is obsolete.

Name of Facility:

Permit No.:

I CERTIFY that during the past seven years the applicant has not been disqualified from participating in any other publicly funded program for violating program requirements. I understand that “publicly-funded” programs are any program or grant funded by federal, state or local government.

Initial: Date:

I CERTIFY that I have liability insurance on my child care facility. If I do not have liability insurance, a written notice has been provided to the parents by me and kept on file.

Initial: Date:

Please sign below stating that all information is true to the best of your knowledge.

Signature:Date:

THE UNDERSIGNED CERTIFIED TO THE FOREGOING FACTS AND TO THE FOLLOWING STATEMENTS:

I understand that Sec. 63-13-10. et seq., Code of Laws of South Carolina, as amended, states that a child care facility cannot begin to operate until a license, approval or registration has been issued to that facility by the Department of Social Services.

Further, it is my intent to comply with the other regulations applicable to this child care facility which include but are not limited to regulations regarding staff:child ratios and supervision of children, beginning with the first day thatcareisprovidedtochildren.Iunderstanditismyresponsibilitytosecurecurrentcriminalhistorybackground records for all facility staff prior to their employment. I understand that it is my responsibility to report to the Department any changes which affect the status of my child care facility license, approval or registration.

Signature:Date:

Section 2: This section to be completed by DSS licensing staff ONLY.

n New n Renewal n License					n Approval n Registration		Permit No.:
Capacity: (Total)			1-4		n Yes n No
(24 Month and Younger):				OR (30 Month and Younger):

Do not enter capacity numbers for both “24 month and under” and “30 month and under.” Only enter the capacity number for the age group designated on the permit issued by the Fire and Life Safety Inspector.

Buildings #1:			#2:		#3:
Permit Expiration Date:								Permit Status: n Regular n Provisional
Liability Insurance: n Yes n No					Approved for Overnight Care: n Yes n No
Type of Facility Applying For:
n Approved Publicly Funded Center/Head Start								n Registered Private For-Profit Center
n Approved Public School								n Registered Private Non-Profit Center
n Licensed Private For-Profit Center								n Registered Faith-Based Sponsored Facility
n Licensed Private Non-Profit Center								n Licensed Group Child Care Home
n Licensed Faith-Based Sponsored Facility								n Licensed Family Child Care Home
								n Registered Family Child Care Home

DSS Form 2902 (NOV 11)

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