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HomeMy WebLinkAboutPart_1Mfg �sJ Instructions and Resource Page for Application for a License to Operate a Family Day Care Horne Instructions: M information can this application must be truthful and correct. Complete this application in its entirety, as appropriate. Not all sections apply. Incomplete applications will not be accepted Please contact the licensing agency if there are any questions relating to this application. *Complete in blue or black ink no white out may be used or strikethrough Use of white out will result in the application being returned to the applicant. Any information that has a strikethrough must be initialed by the applicant *The license, if approved, will be issued in the name of the owneroperator The owned operator may be an individual or a corporation, and the license must be posted in a conspicuous location where the family day care home is operating •The application must be signed by the individual ownerl operator, or the designated representative of the corporation, and must include submission of background screening documents for the owner/operator, and approved fire and environmental health inspections (if applicable). A family day care home will be issued in the name of the owner and for the physical address location identified on the application, •Art application is not considered complete until all documents are received, which includes submission of background screening documents for the ownerleperator: licensure fee. and approved fire and environmental health inspections. must also obtain and provide approval frotn local zoning and building code offices and Horne Owners Association prior to the submission of the application. .A completed application for renewal of an annual license must be submitted to the licensing authority at seas? 45 days prior to the expiration date of the current license to ensure that a lapse of licensure does not occur. Failure to submit a completed application at least 45 days prior to the expiration date of the current license constitutes a licensing violation as defined in paragraph 65C-20.E108(3), i= A C *The issuance of the license is contingent upon the payment of any fines previously imposed as a sanction against an applicant's license that was not contested andlor that was affirmed through the administrative process or an administrative hearing_ .The family day care home license is issued for the physical address location notated on the completed application. .The license is issued try the Department to an owner! operator for a single location and is nor! -transferable between owners and locations. •Every family day care home must hood a valid license or registration prior to operation #VVithin 30 days of receipt of the application. the department must notify the applicant in writing of any error(s) or omission(s) on the application and any additional information needed for the application to be considered complete *The Department has a 90-clay time limit for approving or denying the license once the completed application has been submitted. Remember An application is not camp#ete until at! requirements have been submitted. The submission of a completed appiicitlon Starts the 90-day "dock" for the approval or denial of the license. •For the purpose of issuing a license, any out-of-state criminal offense, which if committed in Florida would constitute a disqualifying felony offense, shall be treated as a disqualifying felony offense for screening purposes `FOR INITIAL LICENSES end RENEWALS, Issuance of ar, inibai License or Renewal of this license is contingent upon the payment of any fines previously imposed as a sanction against this license that was not contested. or that was affirmed at an administrative Bearing If at the time of this license renewal application. there is a pending administrative hearing resulting from a proposed fine, it shall not affect the renewal of this license. Qhapter 435, F S requires oackgrounci screening of ownr rs. operators, h0u5el-101d members and substilutes Social security nUmOers we also used to- ideritfioation ptjrpases when performing the background screening required by 402,305, F,S. CF-r-SP 5133. Appiiccktiofi for a license to Operate a Family Day Care Home, May 2019 65C-20.008[.1 j, F.A C. Page I of 6 APPLICATION FOR A LICENSE TO OPERATE A FAMILY DAY CARE HOME � s .pax PLEASE TYPE OR PRINK' LEGIBLY For Official Use only Sexual Offender Address Cross -Reference htt llcffe 3der.iCl&e.stat.il.us) Bate of Search: _ Conducted by Signature/Initials. ." A,hP USING BLUE OR BLACK INK Exact Address Match: Myf1,1"'kin_If5_com I] Yes ® No Instructions: All Information on this application must be truthful and correct. Complete this application In its entirety, as appropriate. Not all sections apply. Incomplete applications will not be accepted. Please contact the licensing agency if there are any questions relating to this application. *FOR LICENSE RENEWALS ONLY: Renewal of this license is contingent upon the payment of any fines previously imposed as a sanction against this license that was not contested, or that was affirmed at an administrative hearing. If, at the time of this license renewal application, there is a pending administrative hearing resulting from a proposed fine, it shall not affect the renewal of this license. SECTION °I: PROGRAM INFORMATION THIS SECTION MUST EE COMPLETED IN ITS ENTIRETY) Application Type (Choose One): Initial ® `Renewal Year ❑ Revision of Existng License Narne (First Middie and or Maiden Last): , Telephone Number (including area code;. ft tJ f._r�.__....__.._... -- .. Alternate Telephone Number' --_ .._._.._....... ......._..._..—...-- ---------��— __�._ _ ..._.__ .___.......9.3.............._.._........_........... If a fictitious name or other identifying name is to be used, please provide the name here (and you must attach a copy of the Department of S e s fictitious name registration for ClR if appiioable, co plate the Section 2: Corporation below): �d Cd �._ S reei Atfdress (p ysrcal address — not a PO Box = City. County Zip Cade Mailir?c Address, if different __._. E {Via€I Fax Number (including areacoaey F-tAa� addr s1 j� t J ❑ Do Not have E haul € (Q �t" 4 i ..L.ooNot Wish ---toProvide Bate of StrEh: {1 CV/7' Social Security Number*. f! Days and Hours of Operation — please check AM or PM as applicable: Monday Tuesday Wedgy Thin rsday Friday Sat„r urday Sunday ❑ 24 hour care ZAM ❑✓ AM � E]AM [ AM E]AM ❑AM []AM penmg Time: ❑PM ❑PM C? ;v ❑Pt•.tl ❑RM PQPM ❑PM ❑PM ❑AM ❑Ark []AM ❑AM ❑AM ❑AM []AM Closing Time: I�t t �l=k+ C/i�n'M G ❑r aM ❑nip ❑ply Months of Operation:[] School Year Only 2'12 months ❑ Other Number of Children in Care Number of Preschool (ages 0-5j Children: Number of School -Age Children: (including your own): Check all service options that apply: Fttil Day Ralf day Drop -In Night Care Before Schoo# School Readiness 9' R_ 11 ❑ ® ❑ Ater School Weekend Infarfs Care (0-1) Food Served Transportation VPK ❑ ❑ `r❑ ❑ ❑ ❑ (This .space intentionally left blank) Chapter 435, F,S., requires background screening of omers, operators, houserioid members and substitutes. 5o6a1 security numbers afe also used for :derrtification purposes wht n performing the background screening required by 402.305, F S. C,F-FSP 5133, Appr is atlon for a l..icerise to Operate a Famity flay Care Home, May 2019 85C-20.008(1), F A C Page 2 of 6 SECTION 2. 'CORPORATION, if applicable (special Instructions. Upon initial application for child care licensure, attach Articles of Incorporation, which must include the names, the tide/office, address, and telephone number for each member of the Board of Directors, Also attach the name and telephone number of the corporation's registered agent Failure to continuously maintain a registered office andlru registered agent in f=icrida is grounds for revocation of this license. For RENEWAL applications for child care ljoensure attach a current COU of Certificate of StatuslCertifiicate of Authorization from the De aitment of State available through SunSiz.or )Name of Corporation Corporate #: - - ._-, � -11 ...,..,.l - _. _," , _. ` - - - - ... - _.____m�_.._.-__._ — _ ._ __ ... Address of Corporation: irictirporated in which State? If out of state, is the corporation registered to the State of Florida? Yes 0 ria Ztf no, please register prior to submitting an application, State: Zip Code: Telephone Number (ino�udinq area code): Designated Corporate Representative Date of Binh: -IS sacial Secu11 rity tVumber _ _ ..... _ ._ .... _._. ------------- --- -- � SECTION 3: OTHER HOUSEHOLD MEMBERS - I understand through this license, the Qepaftme€tt has the right to conduct: a screening on myself and other family members, which includes, but is not limited to, employment history checks, a criminal record check, and a Central Abuse Hotline Records Search. Use as many lines as needed and attach additional sheets if necessary. NAME RELATIONSHIP [SATE OF BIRTH +CA---06`_(�'�..5ca2—�T 1.0 -- c �:,--d p th SOCIAL SECURITY NUMBER` ... - -+_-- i . ,;a. 5- - 0r �...f l%QY15.._.__._C,%�_,1_..'Z,�S1oC...l� ---- --------- SECTION 4: SUBSTITUTE PLAN THIS SECTION MUST BE COMPLETED IN ITS ENTIRETY Section 402 313(13). Florida Statutes. requires Family Day Care Home operators to provide proof of a written plan for at least one other competent adult to be available to substitute for the operator m an emergency. This plan shad include the name. address, and telephone number of the designated substitute- proof of background screening clearance and completion of required training for the designated substitute must be submitted with this application. Any change to the substitute plan that occurs during the home's licensure year must be submitted to licensing within 5 working days of the change Pieas!�_provide this information below attach additional sheets, if necessary) S Marne of ubstitute: Telephone Number --.. _-. sa_ Date of Birtri: Number of Hours Substitute Works in the Horne Monthly: i^ 2 I cuvts Does the substitute work in another family day care home(s)tlarge family child care home's)? Yes No If yes, please list the names of the other family clay care home(s)tfarge family child care home(S) SECTION 6: OWNER t, F REAL PROPERTY {as the ctarpl t appears can the Aged tq the pra��rty} _ ___-_ Marne tFir5t Middle (N3a+der�) i.asa}; ��� Teleptiflna Number (rncludtng area cadet - -- / `� 3 Owner's Home ddress (street address City: County: ( State tip Erode: Chapter 4352 F,S... requires bartcground screening or uvcmers, operatom householo members and subV,tutes. Social security numtaers are also used for identification purposes when performing We backgroun(S screening required by 402.305, F.5. CF-FSP 5133. Application For a License to Operate a Family Day Care. Home, May 2019. 65C-20.0080j. F.A,C, Page 3 of 6 SECTION 6: ATTESTATION Has the owner, applicant, or director ever had a license denied, revoked, or suspended in any state or jurisdiction, been the subject of a disciplinary action, or been fined while employed in a child care facility's ❑ Yes [I No if yes, please explain: (attach additional sheet(s) if necessary) Have you or anyone identified as a party to ownership ewer held a license (child care, foster care, cosmetology, etc.) with any state agent in any capacity other than a driver's license? E] Yes INo If yes. where, what type of license, licenses number, and under what name? Prior to receiving a license, 1, the ownerloperator, and all known child care personnel and other household members, have sutarnitted background screening information. Z Yes `,m,,,j No If no, please explain (attach additional sheet(s), if necessary): SECTION is HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)1 ACKNOWLEGEMENTS (THIS SECTION MUST BE COMPLETED IN ITS ENTIRETY) The Health Insurance Portability and Accountability Act (HIPAA) requires personally identifiable health information must be protected from disclosure and maintained in a manner to prevent inadvertent disclosure to the public and to otherwise assure the privacy of such Information- Your signature on this application indicates that you agree to comply with the requirements of HIPAA by protecting the confidentiality of employee and children's health records in your possession. Chapter 386.204, Florida Statutes (F.S.), requires while children are in care, smoking is prohibited within the family day care home and in vehicles when transporting children. Family Day Care home and Large Family Child Care Horne Handbook, Section 8.1, A, requires operators of family day care homes to provide proof of current immunization retards. Your signature an this application indicates that you attest to keeping and maintaining current immunization records for children in care and making copies available upon request of the Department. Section 402.313(13), F.S., requires operators of family day cage homes to complete 10 clack hours or 1 continuing education unit of in-service training annually during the registration year. Training must be completed in any course areas relating to child care or child care management. Training may be documented on the In- service Training Record (CF-FSP 5268A) provided to you by the Department or a similar form containing all the information required on the Department's form. This documentation roust be completed annually and made available upon request of the Department_ Section 402.313(6), F.S., requires operators of family day care homes to complete, one time only, 0.5 continuing education unit of approved training in early literacy and language development of children from birth to 5 years of age. Training documentation such as a certificate of course completion or diploma must be maintained and made available upon request of the Department. A list of the Department's approved literacy training programs may be accessed by contacting the department or by going to the Department's child care website at www,myfifamilies.com/childcare, Pursuant to s.39.604, F,S„ each provider roust acknowledge receipt of the reporting requirements and educational stability previsions of the "Rilya Wilson Act". Your signature is on this application indicates acknowledgement of receipt of such information. Your signature on this application indicates your understanding and compliance with all of the aforementioned statutory requirements. Operator's signature: { CJJMf L"0:d1o%(� _ Date: Chapter 435, F s_ requires oacxgg ound svreening ur owners, operators, housshotd rnemtiers said 5utr5iWe5. Social security numbers are also used for identification purposes when perfomiing the background screening required by 402.305. F.S. CF-FwP 5133, Application for a License to Operate a Family Day tare Nome, May 2019: 65C-20,008(1), F.A.C. Page 4 of 6 rut rout jection is a 6LK _iection 8 b as a licable. SECTION $(a); Release of Information (Non -Confidential) Form. You must complete this section if you DO NOT meet the requirement of the public record exemption statutes. Release of Information Family Day Care Home (Non -Confidential) The Department of Children and Families has developed the Statewide Child Care Licensing Information System. All child care arrangements licensed or registered by the Department are included on this website, Addresses of family child care homes will be optional; however, all telephone numbers will be included as a means of contact. This website is a valuable tool and includes a "search screen" to assist parents looking for resources and child care arrangements in their community. In the absence of an address, your home will not be included on the list of available providers when information is requested through an "address search." Each provider may request the address of the family day care horne/large family child care home be included on the website by completing the following: I attest that I am the operator of a registered or licensed family clay care homefiarge family child care home and request the address of my home be included on the child care licensing website along with my telephone number. of Operator ame Yes.. include my address ❑ No, do not include my address LI N IM-re SECTION 8(b): Confirmation of Statutory Confidential Status Form. Complete this section ONLY if you. rn! the c uirements of the yblic record exemption statutes. Confirmation of Statutory Confidential Status Family Day Care Horne Section 119.071, E.S., and other Florida Statutes re uire that names, dates of birth, addresses, telephone numbers, location of schools, and places of employment for specific types of personnel, their spouses and their families be kept confidential. Examples of these types of employees are, Law Enforcement officers investigators of Abuse and Neglect Firefighters i Justices of the Court Child Support Enforcement staff State Attorneys tt Foster parents Employees involved in Revenue Collection State Prosecutors � CountyiMunicipal Code Enforcement officers investigatorsilnspectors of DBPR Public Defenders Human Resources employees Juvenile Justice employees Guardians ad liters i**W$#}fW#;*#}i#N##+'}'*wr'rAWWEi}#f3#,#}y;##}#4YwiN*»»#kk WiTs1ioWff##Nl'#x+tkahki.#t#*e#}t#ifl,t,YWwNRYrfts4*#*ii+*Y.#,YAANS'RW NsrY##Airki irf Mi'.1MW kei 4'#T#Ak Y If you meet the statutory criteria for "Confidential Status," you must submit supporting documentation (ex; coley of business card or a letterfstatement from employer). ❑ I attest that I am a current or former law enforcement officer, rather employee, or the spouse or child of one, who is exempt from public records disclosure under s.119,071. F.S., or other Florida Statutes, and do not want my family day care home/large family child care home demographic information displayed on the child care licensing website. ❑ I attest that I am a current or former lam enforcement officer, other employee, or the spouse or child of one, who is exempt from public records disclosure under s.119.071, F.S., or other Florida Statutes. However, I do want my family day care home/large family child care hone demographic information displayed on the child care licensing website )Tease include the following (check nji one), ❑ Telephone number only ❑ Both the address and telephone number .�? -- 1 � / Signature of Operator Pate Neale of Home : tease rim} Chapter 4n, F.S., requires background screening of owners, operators, household members and substitutes. Social 50cunly numt)ers are also uJ ed for i0eMification purposes vahen performing the background screening required by 402.305, F S_ C;r"-FSP 5133. Application for a License to Operate a Family Clay Care Nome, May 2019, 65C-20.008(1), F A.0 page 9 of 6 SECTION 9: Statements of Corm lianre in accordance with 402.319(3), F.S., each family day care home must annually subs 4 an affidavit of compliance with the envisions of s. CN.201, F.S.. regarding the fe ements of rnanda eq reporter. By signing below, I Q- P� licant of Family tray Care Home, do hereby affirm compliance wrth s. 39.201, F.S. h, Pursuant to section 435.05(3), F.S., each employer rust attest via signed attestatiormpliance with the prov' ions of Chapter 435. F S. re . rdin the st tutary requirements for background screening. By signing below, i I- Applicant o�t.t.+�L �Sa�.v! Family lay Care Home, do hereby attest under penalty of perjury th t I am in compliance with the provisions of Chapter 4J5, F S. Signature of Applicant Date` Chapter 435. F.S.. requires background screening of ovmers, operators. household members and substitutes Social security numbers are also used foi identAicatior purposes when performing the background screening required by 402.305. FS. GF-FSP 5133- Apolt cation for a License to Operate a Family Day Care Horne, May 2013. 65C-2©,008(i).. �.A.0 Page 6 of 6 kVARr�fiy� Ran t7eSantis o State of Florida Governor Department of Children and Families j` shevaun L. Harris y 1 Secretary ;MYR FAMILSES.COM Sharron Washington Regional Managing Family L ay Care Home Director Emergency Care Plan Phase Indicate the availability of emergency care for your family day care home by answering the following questions and return with your license application. - Name & Address 1 _ Substitute: Vj VL Telephone number Yes NO 2. Are there provisions for first aid treatment (Le, bandaids, cotton balls, gauze, adhesive tape, thermometer, tweezers, scissors)? Y 3. Have you completed a standard CPR & first aid training course with a current date 4, Are the emergency phone numbers posted by the Telephone (child abuselneglect hotline, fire, and rescue squad)? -- 5. Do you have the telephone number(s) of parents (s) lguardian in case of emergency? 6. Do You know the name and telephone number of 7. ,,.._-._ - .-.-- — t- r- -- of �An =mr..,m Pnr V' Child Care Regulation - Circuit 19 337 N. U.S. Highway 1, Fart Pierce, FL 34950 Mission: Work in Partnership with Local Communities to Protect the Vulnerable, Promote Strong and Economically Self -Sufficient Families: and Advance Personal and Family Recovery and resiliency State of s. ChildrenDepartment of s Families Ron QeSantis Governor Shevaun L. Harris Secretary Sharron Washington Regional Managing Director FANITIN CH ILD �C RL4' 1-110NIE WORK STATE,' IF'ti T L�I`Iscv-iduaZ�, cis i�ehalf of (Print Name of Operator) ��axnily Child Care home) confirms that I do not work outside of my home during the hours the family clay care home is operating. Operator's Signature 337 N. US Highway 1, Room 327, Fort Pierce. FL 34950 I5ate Mission: Protect the Vulnerable, Promote Strong and Economically Self -Sufficient Families, and Advance Personal and Family Recovery and Resiliency State of Florida Department of Children and Families tor► DeSantis Governor Shevaun L. Harris Secretary Sharron Washington Regional Managing Director FA M1.1-Y Ci 1111) CARL HOME SUBSTI"ITE.711, STATEME'NT This statement confirins that 2E substitutes for �Farnily Child Gaze Home' Have completed all of the required docu ncnts: Fingerprint and Local Law Enforcement Clearance; Attestation of Good Moral C hracter, Ch11r3 Abuse & Neglect Reporting Requirements, and Daycare References. If I change substitutes I will notifs, Child Care Regulation of this change. and I understand it is my responsibilit-Y to make sure all requited documents have been completed for the new substitute. Below is a fist of the substitutes indicating the; number csf hours they work per Month: Name caES€�fistitute(s) Number of Hours Work Monthly 1 3. Operator Signature 9 )Stit_. )Stitute si at ttxe substintt Date --191 Date Date Substitute. Suture - Date 337 N. US Highway 1, Room 327 Fort Pierce, FL 34950 Mission; Protect the Vulnerable, Promote Strong and Economically Self -Sufficient Families, and Advance Personal and Family Rscovery and Resiliency Ran ©eSantis Governor State of lorida Shevaun L. Harris Department of Children andFamilies Secretary w< Sharron Washington Regional Managing Director 1.I N1II_Y CHILI) CARE, H£ NIE PROHIBITION OF SMOKING STATEMENT During hours of open, don there is a sign pasted prohibiting smoking oil the prefi ices Of tnv fatn.ily Child care. Fanlily Child Care Home: signature: Date: 337 N. US Highway i, Fort Pierce; FL 34950 772-467-3536 Mission: Protect the Vulnerable, Promote Strang and Economically Self -Sufficient Families, and Advance Personal and Family Recovery and Resiliency State of Florida Department of Children and Families Ron DeSantis Governor Shevaun L. Harris Secretary Sharron Washington Regional Managing Director J A-MILY CHILD CARE HOME FIRFARM FORM I /we do not own any fireartris ot weapons and no furvarms or weapons are kept In rny'l/rear home. Operator Signamire A O'-'latef Roorn ate S�ignarure 9ramr)flrnd, P Date Date 11"we do own firearm,, and weapons as defined in s- 790,001, F,S,, at all times whell children are in care. all firean-ris and weapons shall be stored in a location inaccessible to children and in accordance with s. 790.174, F.S. Operator Signature Husband, Paramour or Room Mate Sis:m�ature Date Date 337 N. US Highway 1, Room 327, Fort Pierce; FL 34950 Mission: protect the Vulnerable, Promote Strong and Economically Self -Sufficient Families, and Advance Personal and Family Recovery and Resiliency qj-f Central Abase Hotline Record Sears {i>I r F awl (p#ease pr#nt - spgvse fast, mfdd#e, #eat rrem*. ff SPO OV6, fpae print-- frrsl, rrffddis, l�si nears] as an eppliwt for adoption, an applicant for lutsaingtr,egtstratOn. or a t3CF OM", authwize a search for reports of abuse, negfect or abAndonrterrt Investigated pursuant tts CCnapWf 39, Ftorkla Ste MS In *'kmy name Sppeert Wd tt*re �fre 'Verified snctsoattxrs' of rtttaftrQatmsrtt of tt Ohl i(ren). 1 r,ntter5tard I will be giver tt«e *pprorluni� to discuss the findtrtgs Of ft WOrt(`s)_ i further understand ttt l the central tbufe hC�rte sewch is only one part of tre preliminary d 10 itre c*un for adopti A' Otte of tt� requlreMernts reviewed by an agency with VV authWity td timn$e or approve horn" fir the pits of develsenIl o -m at�l!lsat geo persons and Ct��Ft7, mcluding family chlid rarla hortm and facititles, or W OCF entAtoyn'tant fOr the requesting agartcy#€a ity listed below on this form. Applicant Signature: A tat'e: Phone_ w name 1 mvm err V lnrs, the" a+y aignafure tPocanv6pousamay Phone. Spouse Signature C7ate' NQPE: This form FORM s, be submitted e 0 taf ",e gerjC err tt iat the ti � a tftdp°3tcun ar #f lri e. a NOT SUBIA17 CTLY orn Applicant SSPICf L ? 1L�r DOB: -ma's ° Rana: sex: Sprwsa: SSNb2A f30B: Race; ' Sex Prror ntame(s)= Current Address: Address City County State Zip Dates at Adumss C; Courtly State Zip Daps et Ad.ollress Previau a Address: Address f?' �9 r, n l nt — I G. r Courn State 7;p Doles at Address Prevtaas Address: Address W+ty tY / ? O j 3. Reason fbr Record Search: f � bdopdan Applicant;Chapter 63} �j pCF Ernplflyes CChapter 39) ir3,'?i�ation �ppf�nt (Chapters 39, 415. 402 Cr 409) st (NOTE. Searches Of the Ce^trai Abuse Hotline may not be used for any employee 4xmpt 0-se W0rkiP9 for^ DCF j Family child ire. fcsterTsl�erlte rlgraup hams or adoption appf�Gents roust :tat ail CthPjd and adwit I�ousehcld Members On page two of this fit. Do nsrt #ncludo any, faster tare chlidmin. Pia BE COMPLETED sy REQUESTING AGENCI' j :h€id Care Center ��11 Family Child Cate Home fir} FcsterlShe#iarlirnali Grow #ivrre ❑ Rdapcit� child-Carmg Agt:mcy L iCh€Id-P#acanp Agency L.]DD FostarfSrnall Group Home OCA andfor Facility M: FaGYtity/Age'j-}y Nacres: tfdtCSS: Vft t G Goft �{��iing t.Ctat�ss I r derstan + t is a rr,lsdetnearror of €he prat tieproe for ar,y oger r-y to use or relsase abuse::, €tegiect or abandonment informAt on to QIYlers, The, irafarmn Atiun * C'Ct3FidEA[° AL end army be used aniy for the purpose for w€,ic" was aatained. printed Nn v and signAWre of Requeating Faci€ity/A�ancy FOPrea8nt41ive Paf'e of 7 0 CeM4 Atuae Hoons Fowed sew AP�ICANTS FOR FAMILY CHILD CARE, U FORMATION FOR ALL CHILD AND AOULi HOUSEHOLD tJEMBE S EXCEpTFOSTE f p�R RESULTS;Departn*nt or Agency Cornducting Search Use Only) too records Tourid 06th verified t,mdings where ifre applicant was the caretaker respornsible In the final role or, for q lieens�ng, in any role in three repovts wthin a nve year period. I G.Yor11fY4t fi-w i rl fne nviRw are 4sted beta . gate of Sea rdl PFnne:„ Emplay CMd=ing Search, Sia�aturh Pere 2 01 2 `h CHILD CARE C ATTESTATION OF GOOD MORAL CHARACTER x§Yr'irA 31kr�,5S10.0 State of Iticrrida County of G ! as an applicant foe employment with. all. employee of a volunteer for, €tr an applicant to Volunteer ixith,... l allirm and attest under penalty a9 perjury ih it 1 meet tlae mural character requirements ,. Ibr employment, as required by' Chapter 4 W 5 Florida Status , tit that: t hate not been arrested with disposition pending; cr found guilty of, regardless of adjudication. or entered a plea of nolo con1'elidere ur guilty" to, or have been adjudicated delinquent and the record has not bmn sealed or expunged for, an3 offense prohihitr.Yt tinder any of the follo"'4119 Provisions of the 1=loricla Statutes or under any similar statute of another jurisdiction for any of die oflentws listed below: Section 393,135 Relating to: sexual wiswriduct with certain developmentally ciisttt lees clients and rep oriing o1'stacii sexual misconduct Section 394,4593 sexual niiseonduct with certain mental health patients and reporting of such sexual misconduct Section 415.1 1 1 adult abuw, neglect, or exploitation ofug.d p vrsons or disabled adults or failure to report of'such abuse Season 741.28 criminal of envcsthat constitute domestic victence, whether committed in Florida oranother jurisdiction Section 777,04 trtterrtpats_ so)icitation, wed conspiracy Section 782.04 Section 7$2.47 murder in €ntilaughter, aggravated. inanslauv"liter Of an elderly perIll)rt or disabled adult, or aggravateJ manslaughter of a child Section 792,071 vehicular homicide Section 782,09 killing an unborn quick child by injury to the mother Chapter 784 assault, batten`, and culpable riLghgence, if the nliense -3S a felt>ny Section 784.011 assault, ifihe victim of'oftense was a mincer Soc'ttvn 784.03 battery. if the victim of offense was a ininor Section 78701 kidnapping Section 787.02 false. imprrisonment. 5ec'ion 787,025. luring or enticing s child Section 787.04(2) taking, enticing, err removing' i child beyond the state ti nits .kith criminal intent Pending custody proceeding Section 787,0413) carrying a child beyond the'Slate litres with Criminal intent to avoid producing a child it a custody hearing or delivering the child to the designated person section 7911�115(1) exhibitiiig greanns or weapons within 4,000 feet of a school Section 790,115(2) (b) possexsing an eleeiric weapon. n or device, destructive device. or other weapon can cahoot property Sectimi 794.011 sexual barlery Former Section 794.041 prohifaited acts of persons in familial or custod+ai authority Seciion 794,0'; unlawful sexual activity with certain miners Chapitcr 796 prostitution Section 798.02 io d and lasciviow, behavivr Chapter 80f) let4dnes5 and in&cent exposure kction 90&0l arson Section 810.02 burgWy Section 9 10, 14 +-oyeuri,;m- if the offense is a felony Section 810, l 45 video voa eurisim if the oll6se Ls a felony Chapter 812 theft sandlor robber =1 related crimes. if a folony o1'fenw Section 917.563 fraudelent sate of controlled substances_ if the offnse was a felony Section 825.102 abuse. aggravated abuse;, or neglect cif an elderly person or disabled adult Seders 925.1025 lewd or lasciE kilts offenses committed upon or in the prM-n,:e ol'an elderly person or disabled adult SCtiiirt 825.10_ exploitation ofdisabled -adults or elderly parsons, if thi, olten5e tvas a felony Section 926,04 incest Seoimi 827A 3 child abase, aggravated child abuse, or negleci of a child Sec€ion 827,04 contributing to the tlelinquencv or dependency of a child Former Section 827.05 negligent treatment of children Section 827.071 sexual perliartnancc by a child Saflon 943,Ot re'Si"Iing arrest with Vioienee 5ectirn 843.025 depriving a law enforcement- correctiorml. or correctional probation officer nicans of protection or ctr:mmunication `wetion 843,12 aiding in an escape Section 843.13 aiding in the escu of ,lusertlle inmates in vorreulklual institution Chapiri 847 obscene literature Section 874,05 encouraging or recmiting another to join a criminal gang laf2 CF-FSP 1649A Child Care Attestation of Good Moral Character, May 2019, 65C-22.001(7)(a)