The 470 0722 form serves as a vital document for those seeking a license to operate a child care center in Iowa, outlining the process set by the Iowa Department of Human Services. This form covers essential details such as the center's name, contact information, financial type, the specific groups of children it serves (ranging from infants to school-age), and the program's operational schedule. Furthermore, it delves into the legal and ethical background of the owner, applicant, director, or onsite supervisor by inquiring about past disciplinary actions or offenses related to child care or other professional fields. Applicants are required to affirm their and their staff's clean legal record concerning children's mistreatment or any form of abuse. By submitting this form, applicants agree to adhere to regulations under Chapter 237A of the Iowa Code and Section 441 Chapter 109 of the Iowa Administrative Code. Additionally, the form touches on compliance with the Civil Rights Act of 1964, highlighting the prohibition of discrimination based on race, color, or national origin and the ramifications of non-compliance. It also underscores the legal implications of operating without a license, the mandatory reporting of child abuse, and the right to appeal license decisions—accentuating the comprehensive nature of the process and the stringent measures in place to ensure the safety and well-being of children under care.
| Question | Answer |
|---|---|
| Form Name | Form 470 0722 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | form 470 0722, E-mail, 225 470 0722, 1964 |
|
|
Iowa Department of Human Services |
|
|
||||
|
Application for a License to Operate a Child Care Center |
|||||||
|
|
|
|
|
|
|
|
|
Name of Center |
|
|
|
|
|
Phone Number |
||
|
|
|
|
|
|
( |
) |
|
|
|
|
|
|
|
|
|
|
Street |
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
City |
|
State |
|
Zip Code |
County |
|||
|
|
|
|
|
|
|
|
|
Mailing Address |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
City |
|
|
|
State |
Zip Code |
|||
|
|
|
|
|
|
|
|
|
Financial Type |
Non Profit |
Profit |
Tax ID: |
|
|
|
||
|
|
|
|
|
|
|
|
|
Name of Chair of Board |
|
|
|
|
Phone |
|
|
|
|
|
|
|
|
|
( |
) |
|
|
|
|
|
|
|
|
|
|
Name of Owner |
|
|
|
|
|
Phone |
|
|
|
|
|
|
|
|
( |
) |
|
|
|
|
|
|
|
|||
|
|
|
|
|
||||
Program Serves |
Infants |
2 Years |
|
|
||||
|
|
|
||||||
|
Evening care |
Special needs |
||||||
|
|
|
|
|||||
Schedule |
|
|
Summer only |
|||||
|
|
|
|
|
|
|
|
|
Hours and Days Center Open
Has the owner, applicant, director, or onsite supervisor ever had any state license or registration (child care, foster care, plumbing, cosmetology, etc.) with any state agency denied, revoked, or suspended in any state or jurisdiction, been the subject of a disciplinary action, or been fined? (Do not consider driver’s license.)
Yes No |
If yes, please explain: (Attach additional sheets if necessary.) |
|
|
The undersigned, and my staff employed with direct contact with children (and any person living in the facility), shall be free from conviction under any law of any state involving mistreatment of a child or violence against a person, and shall be free from any record of founded sexual abuse or any record of multiple incidents of any other type of founded child abuse (including physical or emotional abuse or neglect). The undersigned hereby makes application for a license to operate a child care center or preschool under Chapter 237A of the Iowa Code, and hereby agrees to adhere to the regulations under Chapter 237A of the Iowa Code and to the rules (minimum requirements) under Section 441 Chapter 109 of the Iowa Administrative Code.
I certify that I have spoken with all of the people mentioned above and I can assert the preceding statements on behalf of the group and myself.
Signature
Title
Date
NOTICE TO CHILD CARE CENTERS
CIVIL RIGHTS ACT OF 1964
Title IV of the Civil Rights Act of 1964 prohibits discrimination on the grounds of race, color or national origin in the administration of the programs under the direction of the Department of Human Services wherein federal funds are involved. The regulations promulgated by the Department of Health and Human Services, implementing the Act, provide that the Department of Human Services must administer the federally aided programs in such a manner that any other agency, institution, organization or person participating in the programs, either through contractual or other arrangements, and receiving payment directly or indirectly from public assistance funds will comply with the terms of the Act and Regulations.
Agencies, institutions and organizations providing care for or placement of children under any program supervised by the Department of Human Services are required to abide by the terms of the Act and Regulations prohibiting discrimination on the basis of race, color or national origin. Failure to comply on the part of child placing agency, child caring institution or day care center will necessitate the withdrawal of Department financial support.
The Regulations provide that any individual who feels that he or others have been the object of discrimination, contrary to the provisions of the Act, by a child placing agency, a child caring institution or day care center may file a complaint with the Department of Human Services or the Federal Department of Health and Human Services. All such complaints will be investigated and appropriate action taken when indicated.
Penalty
A person shall not establish or operate a child care center without obtaining a license. A person who establishes, conducts, manages or operates a center without a license shall be guilty of a serious misdemeanor. Each day of continuing violation after conviction, or notice from the Department of Human Services by certified mail of the violation, shall be considered a separate offense.
Mandatory Reporting of Child Abuse
It is mandatory, under Chapter 232 of the Iowa Code, for the owner or director in charge of a child care center, to report immediately to the Department of Human Services, when in the course of working with a child, the director or an employee has reason to believe that the child has suffered sexual abuse, physical abuse or neglect. This report shall be both oral and written.
Right of Appeal
A person who receives notice from the Department of Human Services denying a license to operate a child care center, or to suspend or revoke such license may appeal to the hearing officer of the Department within 30 days after the date the official notice was mailed.