HomeMy WebLinkAboutPart_2Chapter 99;
drug abuse prvvention and control Curly if the oikn.w was a fidony or if an}01ber person in4olvcti in the ofiinse %X'L4 s
minor
ccl.ion 91fr.10?4
sexual rniwonduci with certain t6reasic clients and reporting ol'snch sexual conduct
Section 944.3 W,
inflicting crttti or inhuman ireaimcm on an inmate resulting in greats hodils. harm
Section 944.441
escape
Section 444.40
hfirboring- conci !';i ng. or aiding an escar3ld pri5Uner
SCCtiCti: 944,47
introductio,) t4contraband into a corfectional facility
seciiorl 984.701
sexual +ni'wooduct ill juv€^nile,jusfice Program",
Vie{-ti(all 985.711
Lontrahand rattroduced iwo deiemion f2i6lides
I understand that I [oust ackno+xledp the �-ximelwe ofanV applicabtc criminal rcc;ord relating to tilt obm'c lists efolfi'nses including those und[ram
similar stature ofano dter iurird` vnn, rettardlcthetor not ihnsc records have b cn scaied or cxpunged. Further. I understand than, while
iwh
co dditr zd f c°odunt# licit* I u+t rr media Ll� ufr rt r>>r;emplo; o of :a y arresttaar dranynchanges in rrtcucriminal�ncord invol�€ing any a
a�
a�n crf�ettapi�aymrnt d rn trcattfv ntr� s � ���-� b , oftht
nhoye listed Prilvisions of f-lorida Swt€itesL or sttratlar stafmcE s tit anolher,lur€sdictiop ai°httiher a misdemeanor eanor or'felony. Z hIS notice mtz o be made x-rthtn
017(s IIUAMcSS day nl'yurh arrest orchargc. J'ailury to do so could be grounds star termination.
I altest that I have Wad the aahoce carefirlk sum sme that am attestalion hire is true and currcct that my reward does not coniuin .any of the above lister(
offenses. I understand. under pena€t} ofperjurr. aail enipioyee4 in such posi#ions of trust car r. ponsibilit; shall aticst to meeting the requirements fur
qualih ia,g Im ernplo inent and agra:Ging to int'0ml. 63V enrpsltaser ill)MC fialely if arrested for arty' of the disqualifying offenses, i afso understand that it is
€ny respollsibility to obtain Clarification can anything urtataincd in this allidavit ti4hich I do riot understand prior to signing, I urn aware that [Inv onlissiuns,
falsiliealivas. misslatenicrlister misreplc ettteuctn5 ntsy disqualify lute from ettrpktyment consideration and. if] am hircCl- n;ty be grounds tier Icrrninntiott
ter denial ofaa exemption <rt a inter dale,
SI(: NA ft fRE :-W�s?i?G�l� Datt:.._1V - C
Sign Above OR Below, DO NOT Sign Both Lines
Ill the best of my kno" fMge and 11cliel. my mcortd Contains fine or More of the applicable disyuuiifying acts or offenses listed ahovc- I have placed
a check mark b, the, offense(s) contained in my record. (If Y.0U ►ra-,e pmviousiy been granted an exvrnplion for this disqualifying oflanzc;. picas;~ arta�l.
ct cope cif lbe letter granting suc;da excarap(kan.) (Please circle €he number %hich corr"ponds to the r f me L(f) contatirteti in your record.
SIGN1"d[ REl
Date:
r 2
In Witness VVhereof, Employee has attested tin Good Moral Character on this date
SiGNRTURE of OumerfDsrector.
2of -3
CF-FSP 1649A Child Care Attestation of Gored Moral Character, May 2019, 65C-22,001(7)(a)
latMRp
CHILD CARE
ATTESTATION OF GOOD MORAL CHARACTER
f ,Pr
w
A§� r1 fA.uiti45i ifki .
State of Florida County of
who<ts art applicant ivr employment %vith, ru-, unpl €ice of, a volt€ ue-cr for, or an applicant to
voltintcer with [ fl ! _. f ly € affirm and attesf tinder penal€g of perjury that i meet the moral character requircments
for ernplovtnent, as required by Chapter 4i5 Florida `Statute�ith�t:
1 have not been arrester] wilb disposition pending or found guilts of, regardless ofadjudioation, or entered a plea ofnolo conlenderc or guilty to, or have
been adjudicated dcliriquent and the record has not been sealCd or expunged for, any, offense prohibited under any cif the fi)llowing provisions of the
Florida Statutes or under any ,similar statute ofanother jurisdiction for ant, of the of%lases listed 1X10w:
Relating tL�=
Section 393.1 35
sexual rniwonducl title certain tieveloprnentally disabled clients and reporting of such sexual misconduct
Section 394.4543
sexual misconduct %& ith certain mcmal health patients and reporting of such +exual misconduct
Section 415,11 1
adult abuse, neglect, or exploitati€n of aged persons or disabled adults or failure to report of s€acli abuse
Section 741.28
criminal opTepses that constitute domrstic violence. whether committed its Florida or another jurisdiction
Section 777.04
attempts. solicitation, and conspiracy
Section 782,04
murder
Section 782,07
manslaughter, aggravated manslaughter ref an elderly person or disabled adult. or aggravated manslaughter of a child
Section 782_071
vehicular homicide
SCeliein 782.09
killing an tinhorn quick child by injury to the mother
Chap€c:r 784
assault. battery, and eulpahle negligence:, if the offense WaS a fciciny
Section 784.011
assault, i€'the victim cif€iffCnsc a Minor
Section 784.03
batter}. iftbc -,icliw €ifoffense was a minor
Section 797.01
kidnapping
Section 787.0k
false imprisonment
Section 787.025
hiring of enticing a child
Section 787,04(2)
taking... enticing, or removing a child lacyfind the state limits vdih criminal imeni pending custody proceeding
Section 787.04(3)
carrying a child beyond the state lines with Criminal intent to avoid producing a child at a custody hearing or delivering the
child to the designated person
Scciio❑ 790.115(1)
exhibiting firearms or weapons within 1,0N) feet of a school
Section 790-1.15(2) (h)
possessing an electric weapon or device. destructive device. or other weapon on school property
Section 794.011
sexual bancry,
1-or€ner Section 794.04 i
prohibited acts ref persons in familial ar Custodial authcirity
Section 794.05
unlawful se.\uirl activity with i;e^ ain minors
Chapter 796
prostitution
Section 798.02
lewd and lasciviow, behavior
Chapter 800
lewdness and indecent exposure
Section 8WOI
arson
Section 810.U2
burglary.
Section 810.14
vo}eurism. if the of)cose is a felony
Section 8 10. 145
vidLu voveurssra, if the offens€: is a felony
Chapter 812
theft andiair robbery and related Grimes. if a felony,° offense
Section &17,50',
fraudulent sale of cowolled substances, if €fie offense was a felony
eetion 825102
abuse, aggras'ated ahusc, or neglect of ate elderly person or disabled aduh
section 825.1025
1cwd or lascivious offenses Committed upon or in the sr nee of an elderly premon or di.Wed .auto]
Section 825.103
exploitation oi' disabled adults or elderly persons, if the offense was a felony
Section 820.04
incest
Section 827.03
child tabus:, aggravated child abuse. or neglect €yfa child
Section 927,04
contributing to the delinquency or dependency of ra child
Former Sccrimi 827.05
negligent rreallnCnt of ehildren
Section 827.071
sexual perfortnanct° by a child
4eeiton 843.01
resisting arntst With b ii)1€mcc
Section 843.02i
depriving a law c€iforePment. Wrrcetivlial, or correcticzn,31 probation, officer rneon5 of'protection of Communication
Section 84 3.12
aiding in an escape
Seel ion 843.I3
aiding in the escape E7f_)i3venf1C ininates in correctional institution
Chapter 847
of asCene. lilerstiire
Section V4,05
encouraging or recruiting another to join a criminal gang
Iof2
CF-FSP 1649A Child Care Attestation of Good Moral Character, May 2019, 65C--22.001(7)(a)
Chapter 993
drn- abufc3 prevcrition and i;otarul Alnk if the f3 cnse %�ljs a lelom or if anv other person involved in the offiensc ixas5 J
starter
Section 9I6,1075
sexual misconduct will] certain forensic. client.-, and reporting ofsuch scxu2l conduct
Section 9443503)
inflicting, cruel or inhuman trca€rnent on an inmate resohin . in great bodily harm
Section 944.40
escape
Section 944A
harboring, ctlnccaliiig, or aiding an escaped prisoner
Scetion 944,47
intrYoduclion ofconl.raband into a CorTectional facllily
fiectioll 05.701
sexual misconduct in jutenile juslic e programs
'_+croon 985"71 1
contraband introdtx:ed into detention Iacififies
i understand that I must act nouledge the existence of anv applicable criminal reed relatint , tt! the above lists of of erases 'including those tinder any
similar staiule, of an€ither.juris " ion. rcg;ardle.. , -,,�Iselitq or not those records li,ivc been sealed or expunged. Further, I undeTsland that. wRile:
to employed or Nolunitering iri any pnsition that reel€tires hackground screen ng as a
Condition of-emlrlpyrtTe.ht. 111)UST hllaliCdidtel} nt3tll " tnv Saj)Brt'l5OT'�efiij3lt3yCi K)f -._.. arreSI and tam° vhanrcs in my criminal record involvitiv any ofibe
abws -ec lisicd provisions of f Ioria9a Statutes or similar siaaotes of another jurisdiction whether a rttisdemeanur or feton�-, 7'€tis notice must he matte within
one business da} ofsucb armst or Charge Failure to do set could be grourizls for termination.
I attest thin I bane read the aboi c carefully and state that m3 attestation here is true and correct that my record dues :not cnniain any of the shoes listed
offenses. I understand. under penalty of crj€ lr .till eaitployces in such positions of trust or oLiponsibilil; Aullf attest to meeting. the requirements for
qualifying fair emplovment and agreeing to ill form the emploler iromccliately° if arrested fir any of the disquatifvingo fenwsz- ] also understand drat it Is
111) reetx)nsibility tit obloin �Jarifivatiotl on anvibing cdraitained in this a]]6davit 1vhjch I do not undermand pries to signing- I tiro avkar£ [liar aft%0rrii5SIOn",
falsifications. niisstaternenti or misrepresentations nisi disq,ua ii� Me f om employmeni consideration and. if] ant hired. rna, tie Lraund for tennination
ordenial ofan cxcrrboat at later date-
®� Z Gate: O
Sian Above OR Below, DO NOT Sign Both Lines
to the I°)t si of my kno%Oedge and beliel; my record contains one or snore of the alaplitalfile disaluatif} ing acts or offenses lasted shove. t home ]paced
a cheek mark h), the offense(N) ciintaincd iri ni; record. flf vc,u hai,e pr%victai5ty been grmvted an exeanption fior this disqualifving offense. Please a€inch
a copy of' the lenvr granting such exetnplion, ) (please eircie the number v'-hieh 0orresponds to the oflenws) contained in your record.)
4IfiNAVUIll
Date:
in Witness bAinerecf, Fmpioyee has attested to Good Moral Character on this date �v!
SIGNATURE of C)vvnerf0irector.
2of 2
CF-F5P 1649A Child Care Attestation of Good Moral Character, May 2019; 65C-22.001(7)(a)
f P=i rn Ry�6
s
b9 C
i
Child Abuse & Neglect Reporting Requirements
All child care personnel are mandated by law to report their EMEgiR M of child abuse, neglect,
or abandonment to the Florida Abuse Hotline In accordance with s. 39.201 of the Florida
Statutes (F.S.).
Child care personnel must be alert to the physical and behavioral indicators of child abuse and
neglect. "Child Abuse or Neglect" is defined in s. 39,201, F.S., as "harm or threatened harm" to a
child's health (mental or physical) or welfare by the acts or omissions by a parent, adult household
member, other person responsible for the child's welfare, or for purposes of reporting requirements
by any person.
Categories include:
- Physical Abuse or Neglect (i.e. unexplained bruises, hunger, lack of supervision...)
Emotional Abuse or Neglect (Le. impairment in the ability to function, depression...)
- Sexual Abuse (i.e. withdrawal, excessive crying, physical symptoms...)
p Reports must be made immediately to the Florida Abuse Hotline Information System by
- Telephone at 1-800-96-ABUSE(1-800-962-2873), or
Fax at 1-800-914-0004, or
Online at http:liwww.dof.state.fl.us/abusL-/report/.
Failure to perform duties of a mandatory reporter pursuant to s. 39,201, F.S. constitutes a violation
of the standards in ss. 402.301-319, F.S. and is a felony of the third degree. Remember, it is each
child care personnel's responsibility to report suspected abuse and/or neglect.
All reports are confidential, However, persons who are mandated reporters (child care personnel)
are required to give their name when making a report,
It is important to give as much identifying and factual information as possible when making a report.
* Any person, when acting in good faith, is immune from liability in accordance with s_ 39.203(1)(a),
F.S.
* For more information about child abuse and neglect, visit the Department's website at
www myflfamilies.comiechildcare and select "Training & Credentiaiing." The Department offers a 4-
hour identifying and Reporting Child Abuse and Neglect course for child care providers. This
course is an overview of the various types of abuse and neglect, indicators that may be observed;
the legal responsibility of mandatory reporters, and the proper procedure for reporting abuse and
neglect, as required by ss. 402.306(2) and 402.313(1), F,S. The course is oZed Lott' online and
instructor -based throughout Florida.
This statement is to verify that onQL- 21 20 ?L, 1, _bjA4
Date Print Name of
Read and understO d the information and my mandated reporting requirements,
of rilpl{3ye' ta w ta*nip et3a ,ire t*r y�: eSignaiure of Q
CF-FSP 5u37. a'3ctotrer 2t117 65C-22 001(7)(t). F.rA%.
pl Px R:bv Child Abuse & Neglect Reporting Requirements
All child care personnel are mandated by law to report their suspicions of child abuse, neglect,
or abandonment to the Florida Abuse Hotline in accordance with s. 39.201 of the Florida
Statutes (F.S.).
Guild care personnel must be alert to the physical and behavioral indicators of child abuse and
neglect. "Child Abuse or Neglect" is defined in s. 39.201, F.S., as "harm or threatened harm" to a
child's health (mental or physical) or welfare by the acts or omissions by a parent, adult household
member, other person responsible for the child's welfare, or for purposes of reporting requirements
by any person.
Categories include:
- Physical Abuse or Neglect (Le [unexplained bruises, hunger. lack of supervision...)
- Emotional Abuse or Neglect (i e. impairment in the ability to function, depression...}
- Sexual Abuse (i.e, withdrawal, excessive crying, physical symptoms—)
Reports must be trade immediately to the Florida Abuse hotline Information System by
- Telephone at 1-800-96-ABUSE (1-800-962-2873), or
- Fax at 1-800-914-0004, or
- Online at hftp,//www.dcf.state,fl,us/abuse/reporti.
Failure to perform duties of a mandatory reporter pursuant to s. 39.201, F-S. constitutes a violation
of the standards in ss. 402,301-319, F.S. and is a felony of the third degree. Remember, it is each
child care personnel's responsibility to report suspected abuse and/or neglect.
* All reports are confidential. However, persons who are mandated reporters (child care personnel)
are required to give their name when making a report.
* It is important to give as much identifying and factual information as possible when making a report.
Any person, when acting in good faith, is immune from liability in accordance with s. 39.203(1)(a),
F.S.
For more information about child abuse and neglect, visit the Department's website at
vA,v-v yfifamilies.corriichildcare and select "Training & Credentialing." The Department offers a 4-
hour Identifying and Repotting Child Abuse and Neglect course for child care providers. This
course is an overview of the various types of abuse and neglect, indicators that may be observed,
the legal responsibility of mandatory reporters, and the proper procedure for reporting abuse and
neglect, as required by ss. 402.305(2) and 402.313(9), F.S. The course is offered both online and
instruct€ir-based throughout Florida.
This statement is to verify that on % , 20, I,{Jt� vc _
®ate print tame of
Read and undersjoQd the info rnation and my mandated reporting requirements.
nature of _—byeE Signature of Operator
CF:4-SP 5337, Gctnber 2017 FSC-22 Wb €r7g(J) F KC.
Child Abuse & Neglect Reporting Requirements
All child care personnel are mandated by law to report their suseicions of child abuse, neglect,
or abandonment to the Florida Abuse Hotline in accordance with s. 39.201 of the Florida
Statutes (F.S.).
Child rare personnel must be alert to the physical and behavioral indicators of child abuse and
neglect. "Child Abuse or Neglect" is defined in s. 39.201, FISr, as "harm or threatened harm" to a
child's health (mental or physical) or welfare by the acts or omissions by a parent, adult household
member, other person responsible for the child's welfare, or for purposes of reporting requirements
by any person_
Categoriesinclude:
- Physical Abuse or Neglect (i,e. unexplained bruises, hunger, lack of supervision_)
- Emotional Abuse or Neglect (i.e, impairment in the ability to function, depression...)
- Sexual Abuse (i,e. withdrawal, excessive crying, physical symptoms-..)
Reports must be made immediately tQ the Florida Abuse Hotline Information System by
Telephone at 1-800-96-ABUSE (1-800-962-2873), or
Fax at 1-800-914-0004, or
Online at http:/Iwww,dcf,state.fl.us/abuseireporti.
Failure to perform duties of a mandatory reporter pursuant to s, 39.201, F.S. constitutes a violation
of the standards in ss, 402,301-310, F. S. and is a feiony of the third degree. Remember, it is each
child rare personnel's responsibility to report suspected abuse and/or neglect.
All reports are confidential. However, persons who are mandated reporters (child care personnel)
are required to give their name when making a report.
* It is important to give as much identifying and factual information as possible when making a report.
Any person, when acting in good faith, is immune from liabiifty in accordance with s. 39.203(1)(a),
F. S.
For more information about child abuse and neglect, visit the Department's welosite at
www.myflfamiiies.com/childcare and select "Training & Credential fing. " The Department offers a 4-
hour Identifying and Repotting Child Abuse and Neglect course for child care providers. This
course is an overview of the various types of abuse and neglect, indicators that may be observed.
the legal responsibility of mandatory reporters, and the proper procedure for reporting abuse and
neglect, as required by ss. 402.305(2) and 402.313(1), FS, The course is offered both online and
instructor -based throughout Florida.
This statement is to verify that on 20 '1A
_4� 1, i-� K-L AJ AZ LEYA',i�_V �L)_
Date Print Name of Employee
Read and underst d th information and my mandated reporting requirements.
r0'& e /-1 ,, 17 0,VV10A_eXLNL&_f� �tz�zz �V
S NZW reof E t ployee {fv iae:!ay S, Ac 9wv,y cM;id care :,Orm, Signature of Operator
CF-f-3F 5337, October 2017 65C-22.001(7)(T), F,A 0
DAY CARE, REFf.'RENCES
Owner f Operator/Subsnturc.
Address
C_
r
Ron Cie Santis
Governor
Sheuaun L. Harris
Secretary
Sharron Washington
Regional Managing Director
PLEASE LIST ALL PkEV IOUS F 1vfI' 1C)YERS FOR 'I'NE PAST FIVF''EARS, M1.N 11 lU,11, .ANI)
M :ST INCLUDE AT LEAST `I HE L .ST TIIREF: EMPLO3 TRS:
I-NAMI' ANI) ADDRESS OF EMPLC'3YER
I`I?.LT-. PI-IONE NUN-iBER [ o�a� � 3 3 P0,-'1]1(__)N Iml-D
DATES OF L;3\I1"Lt)YN1I:NT
2-Nr\iffl_AND ADDRESS, OF FMPL0Y'1`:R � ���v?�
'I`FT.I'TfION F NUM}3ER 15k PC34I'1.10Nr 14F:LD
DATh'S OF EMPLOYMENT
3-NAME AND ADDRESS OF ENIPI-C:)Y R
POSITION HJ'!�J ,.)
DA-fT.S OF FMPLOYI41.`N.I°
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
� Ron DeSantis
State of Florida Governor
T Department of Children and Families
tv
Shevaun L, Harris
Secretary
A
tv4YFI.FAmiLiES.COM
Sharron Washington
Regional Managing
Director
SUPPLEMENT TO APPLICATION FOR CHILD CARE
(Section 402.3055 (1) (a) (b) F.S.
Have you ever had a license denied, revoked, or suspended in any state or jurisdiction
or have been the subject of a disciplinary action or been fin while employed in a child
care facility or family day care home? Yes No If yes, please explain
(attach additional sheet(s) if necessary)
Have you ever worked in a facility or family day care home that has had a license
denied, revoked, or suspended in any state or jurisdiction or has been the subject of a
disciplinary action or been fin ` while employed in a child care facility or family day care
home? Yes Noif yes, please explain (attach additional sheet(s) if
necessary)
UNDER PENALTY OF PURJURY, I ATTEST THAT THE INFORMATION GIVEN
ABOVE IS ACCURATE. 4
Appiicant/Employee/Substitute Signature (y Date
Sworn to and subscribed before me this .,.._._ _/ __day of .-20g_.
Online Notarization
hysical Presence
y reduced Identification
of Ident
I-
GAP,CL SHAMIS
Signa Cire o otary of Florida
y C.� lir icn GG 2552n0
24, 2022
F,ondz: Ihr-,.i'-; it %.:a., ;a�. N0A!yAss5.
337 N US Highway 1, Fort Pierce, Florida 34950
Mission: Work in Partnership with Local Communities to Protect the Vulnerable, Promote Strang and
Economically Self -Sufficient Families, and Advance Personal and family Recovery and Resiliency
OEPARp
Ron DeSantis
o State of Florida Governor
Department of Children and Families
Shevaun L. Harris
�116,€, Secretary
A. N
MyFLFAMtf_1fS.00M
Sharron Washington
Regional Managing
Director
SUPPLEMENT TO APPLICATION FOR CHILD CARE
(Section 402.3055 (1) (a) (b) F.S.
Have you ever had a license denied, revoked, or suspended in any state or jurisdiction
or have been the subject of a disciplinary action or been fined while employed in a child
care facility or family day care Dome? Yes No ,/ If yes, please explain
(attach additional sheet(s) if necessary)
Have you ever worked in a facility or family day care home that has had a license
denied, revoked, or suspended in any state or jurisdiction or has been the subject of a
disciplinary action or been f'ned while employed in a child care facility car family day care
home'? Yes No � if yes, please explain (attach additional sheet(s) if
necessary)
UNDER PENALTY OF PURJURY, I ATTEST THAT THE INFORMATION GIVEN
IS ACCURATE.
cant/Employee/Substitute
Sworn to and subscribed before me this l day of
Online Notarization
Physical Presence
Y-qQ
Date
0
^i Con CAROL
#SHAi"YP
utif Flurialcn-Stote S
Notary o
GG255268 Mly Comm cxpfres Sep 2d, 2022
�� Gonde� through t�lafi:�nal Notary Assn.
L- roduced Identification t
Fo of l ntification
Signet o otary
337 N US Highway i, Fart Pierce, Florida 34950
k issionr Work in Partnership with Local Communities to Protect the Vulnerable, Promote Strong and
EconornicaUy Self -Sufficient Families, and Advance Personal and Family Recovery and Resiliency
�ptPAA?.
F1�
AN
MYF t FxMa t,I r s.ccsM
State of Florida
Department of Children and Families
Ron DeSantis
Governor
Shevaun L. Harris
Secretary
Sharron Washington
Regional Managing Director
ACKN0VJ.,EDGF,MLNT(.)F CAPACITY 1t1;GLILATIONS
To Child Care Regulati€ m
As a Licensed family clan care honle provider, I fully understand that I am perm rted by law to care
for € my one of the followmg groups of children, including niv own children under the age of 13:
(a} taxia urea of foci- O children horn birth rap to twelve (12) Months of age.
(b) Maximum of three (3) children from birth to twelve (12) months of age, and other children,
for a rr ximum total cif six (6).
(c) Nta\imum of six (6) Preschool children if they are all older than twelve (12) months of age.
G{d) i Maximum of ten (10)1 children if no more than five (5) are: preschool af;c and, of those five
(5), no more than two (2) are under Melve (12) months of age.
I aria aware that violotions of farrz lv day care home registration recluirernents are subject to
adraairristrative f ne:z and revocation of my license.
Si&tature of Operator
Print Operator Name
Address
City Stag Co
de
ode
337 N, US Highway 1, Room 327 Fart Pierce, FL 34950
Mission, Protect the Vulnerable, Promote Strang and Economically Self -Sufficient Families, and
Advance Personal and Family Recovery and Resiliency