Application for a Large Family Child Care Home Endorsement

Child care provider information (section 1 of 4)
Legal name

First NameLast Name
Location of licensed family child care home

Street Address

Street Address Line 2

CityState

Zip code
Is your facility address the same as your mailing address?
Mailing address

Street Address

Street Address Line 2

CityState

Zip codeCountry
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you expect to make changes to your reported business hours?
What changes do you plan to make to your business hours?
For example: September to June / Mon. to Wed. / 9 a.m. to 12 p.m.
Do you have a job outside the home?
Describe your job and the hours you work.

Staff members (section 3 of 4)
All staff (including assistants and substitutes) working in your family child care home must be listed as “current” on the providers Background Check Information System (BCIS) roster.

If you don't have currently have approved staff working in your child care program, you need to ensure adequate staffing before you can get approved. Use the the staff application.
Do you have approved staff members?
Information about approved staff members
Have you submitted applications for staff for approval?
Information about staff members pending approval
Do you have employees in your program that require Worker’s Compensation?
If you hire employees to work in your program, State law (CGS Section 31-286a(b)) requires that no state department, board or agency may issue a license or permit to operate a business in this state unless the applicant first presents sufficient evidence of current compliance with the worker's compensation insurance coverage requirements of Section 31-284. For more information contact your insurance agent or learn more about Worker’s Compensation.
Name of insurer
Insurance policy number
Workers' compensation coverage effective from

MonthDayYear
To

MonthDayYear

Required attachments (section 4 of 4)
Facility information

Not required if you've previously applied for the Large Family Endorsement
Indoor space

To be considered, your program facility must have at least 35 square feet of useable indoor space per child.

Outdoor space

Your program must also have 75 square feet of outdoor space per child for the number of children using it any one time.

See a sample floor plan.
Upload a detailed floor plan showing indoor and outdoor space.

Indoor: Include dimensions of each room intended to be used for child care, labeling of each room/area (including basements, hallways, bathrooms, kitchens), entrances and exits, doors and windows, and storage areas. Outdoor: Include dimensions, location, and any fences or barriers (if applicable).
Cancelof

Ready to submit?

Make sure to review your responses first.
Because your information hasn't changed since your last application, we'll use what we already have on file. Fill out your name, license number, sign, and submit below to confirm.
Name of licensee

First NameLast Name
License number
Signature of licensee
Today's date

MonthDayYear
Please verify that you are human
Should be Empty:

About this application