Form Il444 3461 – Fill Out and Use This PDF

State of Illinois

Department of Human Services

License Exempt Child Care Center Self-Certification

Name of Agency/Program/Facility:		FEIN:

Address:

City, State, Zip Code:

Phone Number:		Fax Number:

E-mail Address:

Contact Person:

Please complete the following information as applicable

	Ages	Number of	Number of Staff	Child/Staff
		Children		Ratio
	Infants
	Toddlers
	Twos
	3's & 4's
	Kindergarten
	School Age

Indicate the hours of operation

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

IL444-3461 (R-6-08)

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State of Illinois

Department of Human Services

License Exempt Child Care Center Self-Certification

1. Services are provided exclusively to children who have attained the age of 3 years and the program is operated by public or private elementary school system; secondary school unit; or institution of higher learning. This exemption includes programs operated by institutions of higher learning as laboratories for the training of their adult students as part of their regular academic curriculum, whether the program is on the campus of the institution of higher learning or at other facilities controlled by the institution.

2. Services are provided exclusively to children who have attained the age of 3 years and the program is recognized by the Illinois State Board of Education.

3. Services are provided exclusively to children who have attained the age of 3 years and the program is operated by a school registered with the Illinois State Board of Education and is recognized or accredited by a national or multi-state educational organization or association which regularly recognizes or accredits schools such as Association Montessori Internationale or the American Montessori Society.

4. Services are provided exclusively to children who have attained the age of 3 years and the program serves handicapped children less than 21 years of age and is registered with and approved by the Illinois State Board of Education and meets the standards of the Illinois State Fire Marshal.

5. Services are provided exclusively to children who have attained the age of 3 years and the program provides primarily religious education as part of the instructional program of an elementary school operated by a church or religious organization and also meets the following criteria:

a)Receives no governmental aid or assistance other than exemption from taxation as a non-profit organization.

b)Complies with the fire safety standards of the Illinois State Fire Marshal (41 Ill. Adm. Code 100); or complies with local fire prevention and safety standards for schools which are equal to or higher than rules adopted by the Ililnois State Fire Marshal; or complies with Illinois State Board of Education Rule 200, Efficient and Adequate Standards for the Construction of Schools (23 Ill. Adm. Code 175);

c)Complies with the standards of the Illinois Department of Public Health (77 Ill. Adm. Code 750) or the local health department; and

d)Either offers classes for the first through the sixth grade or offers classes from the levels of nursery school or kindergarten through at least the first grade with a plan to offer classes through the sixth grade within five years.

6. The facility is operated in connection with a shopping center or service, religious service, or other similar facility, where transient children are cared for temporarily while parents or custodians of the children are occupied on the premises and are readily available.

7. Any Type of day care center that is conducted on federal government premises.

8. Special activities programs, including athletics, crafts instruction and similar activities conducted on an organized and periodic basis by civic, charitable and governmental organizations.

IL444-3461 (R-6-08)

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State of Illinois

Department of Human Services

License Exempt Child Care Center Self-Certification

9. A part day child care facility conducted by (or operated by) a church, religious organization or social service agency that:

a)complies with the standards of the Illinois Department of Public Health (77Ill. Adm. Code 750) or the local health department;

b)complies with the fire safety standards of the Illinois State Fire Marshal (41 Ill. Adm. Code 100);

c)does not provide care for any child for more than eight hours in any given day;

d)does not provide care for any child for more than 10 hours in a 7 day week;

e)provides at least one caregiver per 20 children; and

f)complies with all other provisions of Sections 2.10, 3b, and 7.1 of the Child Care Act.

Part day child care facilities must attach verification of this exemption from their local DCFS licensing office.

Director's Signature

Date

Director's Printed Name

Check List

*The following forms must be completed and returned to your local Child Care Resource and Referral Agency:

*A copy of the License Exempt Child Care Center Self Certification Form (including your health and safety standard checklist).

*Completed Child Abuse and Neglect Tracking System (CANTS) forms for all employees.

* A health report signed by a physician for your director and all staff must be on file in your center.

*At the discretion of the Department of Human Services, you may be required to furnish a letter from the Illinois Department of Children and Family Services that verifies your license exempt status.

*Part day child care facilities conducted by or operated by a church, religious organization or social service agency must submit written confirmation of the exemption from the local DCFS licensing office.

IL444-3461 (R-6-08)

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