Specialized Group Facility – Change in Sponsoring Agency

FACILITY INFORMATION

License Number *

Phone *

Name of Group Home or Group Center *

School District *

Location Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is there a mailing address that is different from the location address?

Yes

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Current Sponsoring and Supervising Agency

Legal Name of Current Sponsoring and Supervising Agency *

Private Child Placement Agency or County Department of Human/Social Services

Current Provider ID Number *

Current Provider Phone Number *

Name of Current Child Care Licensing Specialist: *

First

Last

Date Current Sponsoring Agency Terminates Sponsorship: *

Written Notification Given? *

Yes
No

Current Sponsor and Supervising Agency Location Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is there a mailing address that is different from the location address?

Yes

Current Sponsor and Supervising Agency Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

New Sponsoring and Supervising Agency

Legal Name of New Sponsoring and Supervising Agency *

Private Child Placement Agency or County Department of Human/Social Services

New Provider ID Number *

New Provider Phone Number *

Name of New Child Care Licensing Specialist *

First

Last

Date New Sponsoring Agency Assumes Sponsorship *

New Sponsor and Supervising Agency Location Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is there a mailing address that is different from the location address?

Yes

New Sponsor and Supervising Agency Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Attestations

Attestation of New Sponsoring Agency: By signature below the new Sponsoring Agency attests that all requirements of a sponsoring agency enumerated in the Colorado Code of Regulations rules regarding Specialized Group Facilities under rule section 7.709 and the Child Placement Agency staff qualification rules found at section 7.710 have been met.

Child Placement Agency or County Department Official as Sponsoring *

First

Last

Title *

Signature

Clear Signature

Name of Child Placing Agency or County Department official supervising the specialized group facility per (7.709.22) *

First

Last

Signature *

Clear Signature

Does supervisor have a MSW? *

Yes
No

Specialized Group Facility – Change in Sponsoring Agency

FACILITY INFORMATION

Current Sponsoring and Supervising Agency

New Sponsoring and Supervising Agency

Attestations

Related Resources

CDHS-External-Trails-Access-Request-Form-Extender-07212021

Colorado Cross-Systems Training Institute

How to respond to a Report of Inspection

How to prepare for a Licensing visit

Facility Application Fee Chart

Interstate Compact on the Placement of Children (ICPC) website

Provider & County Appeals and Waivers

Sample Mandatory Reporter acknowledgement

Facility Child Abuse and Neglect (Trails) Request

Child Care License – Application for Renewal

Child Care License – Original Application & Attachments

Provider Services – Appeal/Waiver Application