Address* (Street) (Town) (Zip) Unlisted Phone*: Yes No Accepts Referrals * yes no. Publish on the Web* Yes No. Do you live at this address?

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1 APPLICATION TO UPGRADE A FAMILY CHILD CARE LICENSE or ASSISTANT CERTIFICATE Please Type or Print all Answers (*Required Information) Information About You Please list the address where you will be providing family child care. If that address is different from your home address, complete the mailing address section Name* * (Street) (Town) (Zip) Telephone* Cell Unlisted Phone*: Yes No Accepts Referrals * yes no Publish on the Web* Yes No Mailing Do you live at this address? Yes No (optional) I am applying to: Household Members Upgrade to a FCCP License Upgrade to a LFCC License Upgrade to a Certified FCC Plus Assistant Certificate Upgrade to a Certified Large FCC Assistant Certificate Date Number of Hours Present Name of Birth Relationship During Child Care Operation Providers only, please list any changes in your household members (including foster children and any person regularly on the premises where you will be providing family child care). For Department Use Only ID# Licensor Code Expiration Date Amount Received $ Date Page 1 of 7 FCCUpgradeApplication

2 License Status and Capacity Refer to the licensing guide section titled Number of Children for more information. How many child care children do you want to be licensed for? Are you providing any evening, night or 24 hour care? Yes No PROVIDERS: Are you working with an Assistant(s) Yes No (LFCC Providers are required to have an Assistant prior to receiving their upgrade.) 1. Assistant s Name Certificate ID# Certificate Expiration Date 2. Assistant s Name Certificate ID# Certificate Expiration Date ASSISTANTS: Are you currently working in a licensed child care home? Yes No 1. Provider s Name License # License Expiration Date 2. Provider s Name License # License Expiration Date Page 2 of 7 FCCUpgradeApplication

3 Indoor Space (providers only) Family Child Care Can Only be Provided in Approved Space Please identify any changes in your indoor space. Please list any rooms you wish to have added for approval or have stopped using for child care. Add/Delete Room Use Size Floor Level Outdoor Space (providers only) Have there been any changes since your last application in what you are using for outdoor play space? Yes No Background Information (all applicants) 1. Within the past three (3) years has any child care child in your care suffered serious illness or injury, been hospitalized, or needed emergency medical treatment as a result of something that happened while in Family Child Care? Yes No 2. Are you, or any other person living in or regularly on the premises of the family child care home, currently under investigation for physical and/or sexual abuse or neglect of a child? Yes No Page 3 of 7 FCCUpgradeApplication

4 Background Information cont d 3. Have you, or any other person living in or regularly on the premises of the family child care home, ever been found to have physically and/or sexually abused or neglected a child? Yes No 4. Have you, or any other person living in me or regularly on the premises of the family child care home, been identified to be the parent of a child who has been adjudicated (legally found) to be in need of care and protection? Yes No 5. Have you or any other person living in or regularly on the premises of the family child care home, had a restraining order issued against you/them or requested a restraining order for protection? Yes No If you answered yes to any of the above statements, please explain 6. Have you or any person living in or regularly on the premises of the family child care home been arrested or charged with a crime of any kind? (Failure to disclose criminal history may be grounds for disqualification no matter what the crime.) a. an offense involving physical or sexual abuse of a child or adult? Yes No b. an offense involving rape of a child or adult? Yes No c. any other offense involving children? Yes No d. any other criminal offense? Yes No If you answered yes to any of the previous statements please explain Page 4 of 7 FCCUpgradeApplication

5 Background Information cont d 7. Are there any outstanding defaults or warrants against you or any adult member of the family child care home or any adult regularly on the premises of the family child care home? Yes No 8. Do you, or any other person living in or regularly on the premises of the family child care home, use alcoholic beverages, narcotics or other drugs to an extent or in a manner that impairs your ability to care for children properly? Yes No 9. Have you ever been listed on any sexual offender record registry? Yes No Page 5 of 7 FCCUpgradeApplication

6 PLEASE READ CAREFULLY AND SIGN BELOW I have read and understand this application. I understand that furnishing or making any misleading or false statements or reports anywhere in this application is grounds to revoke, suspend, refuse to issue or refuse to renew my license/certificate. To the best of my knowledge, the information I have provided and the responses I have given are true. I have read 102 CMR 8.00 Standards for the Licensure of Family Child Care and Large Family Child Care Homes, and I agree only to work in a family child care home in compliance with the Department of Early Education and Care Family Child Care Regulations. Signed under pains and penalties of perjury: Date Signature of applicant TAX CERTIFICATION STATEMENT I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name (mandatory) *By: Corporate Officer (mandatory, if applicable) **Social Security # (voluntary) or Federal ID# Date *This license will not be issued unless this certification clause is signed by the applicant. **Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing and tax payment obligations. Licensees who fail to correct their non-filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law c62c 5.49A. Page 6 of 7 FCCUpgradeApplication

7 Please complete this sheet if you need any additional technical assistance. Technical Assistance If you have concerns, questions, or would like information about regulations or policy issues, or other topics that affect your child care, please list below. (For example, if you need information on behavior management, planning activities for mixed-age groups, setting up your environment, reflecting the cultural diversity of the children in your care, etc.) This will assist you in preparing for the licensing process and enable your licensor to bring or send you resource materials, if available. Page 7 of 7 FCCUpgradeApplication