Child Placement Agency License – Application for Renewal

(Use Original Application for Child Care Facility to add additional services)

FACILITY INFORMATION

ADMINISTRATIVE INFORMATION

Personnel

Attestations

The undersigned hereby applies for a license to operate a child care agency under 26-6-901 et seq, current Colorado Revised Statutes, as amended, and certifies the following:

I have read and am fully familiar with the licensing rules regulating child care facilities issued by the Colorado Department of Human Services, including the General Rules for Child Care Facilities, and I agree to fully comply with them.

I understand that before a license is issued, an investigation must be completed, and I will cooperate with the Department of Human Services in its investigation to determine conformity with the regulations.

I understand that if issued a license, it will designate types of foster homes the agency is approved to certify. Further, I understand that if I fail to maintain the rules and regulations, the license is subject to suspension or revocation or may be changed to probationary and/or the facility may be subjected to fines.

I hereby give authorization to the Department to obtain reports of child abuse and neglect and to review the State Automated Case Management System for child protection issues pursuant to state law.

I understand that the owner, applicant, director of agency, and all employees of the child care agency are required to submit a complete set of fingerprints to the Colorado Bureau of Investigation, and that all costs will be borne by the owner, applicant, director, or employee of the child care agency.

I agree to adhere to the non-discrimination provisions of the Title VI of the Civil Rights Act of 1964, The Age Discrimination Act of 1975, and the Rehabilitation Act of 1973, and Titles I through V of the Americans with Disabilities Act, as amended, and their implementation regulations which prohibit discrimination on the grounds of race, color, national origin, age, or disability.

I understand that upon receipt by the Colorado Department of Human Services, this application becomes a public record.

I understand that the application fee is non-refundable.

I understand that providing false information to the Colorado Department of Human Services could result in my being fined as much as $250 per day to a maximum of $10,000 pursuant to section 26-6-921, C.R.S., and the license application being denied.

I understand that should I knowingly or willfully make a false statement of any material fact or thing in this application, I am guilty of perjury in the second degree as defined in Section 18-8-503, Colorado Revised Statutes, and, upon conviction, shall be punished accordingly.

I understand that as a licensed Child Placement Agency, I must ensure that all foster parent files are maintained in accordance with all applicable requirements, and that if the foster parent files are not maintained in accordance with all applicable requirements, that the child placement agency license is subject to suspension, revocation, or may be changed to probationary, and/or the agency may be fined.