• Type of Facility

  • Name of Applicant:

  • Date of Survey:

  • Persons Living in Home (including Applicant) / Birthday / Relationship

  • Number of chlldren in care under 18 months:

  • Number of chlldren in care 18 months to 2 1/2 years:

  • Number of children in care 2 1/2 years to Kindergarten:

  • Number of children in care Kindergarten to 14 years:

  • Number of children in care 14 to 16 years:


  • 1. Number of children in care meets State of Kansas child care regulations

  • 2. Other employees in child care facility?

  • How many:

  • 3. Emergency numbers are listed by or on the phone

4. The following information is available for each child:

  • a. Name, address, and place of employment of parents

  • b. Health assessments for children in care

  • c. Parental permission for emergency care

5. Health certificates for:

  • a. Provider

  • b. All family members living in the home

  • c. All employees

  • 6. Dog(s), cat(s) have current rabies shot.

  • How many pets:

7. Completed plans for:

  • a. Evacuating children in case of fire.

  • b. Shelter for children in case of tornado.

8. The home:

  • a. Is safe and free of hazards

  • b. Has second exit readily available from first floor

  • c. Has fire extinguisher in the kitchen

  • d. Has medication, household poisons, sharp knives and scissors stored out of reach of children

  • e. Has gas stoves/space heaters properly vented and guarded

  • f. Has electrical outlets covered

  • g. Has approved fire inspection

  • Select date

  • 9. Meals for children in care are prepared within the facility

10. Outdoor play area:

  • a. Is fenced

  • b. Is free of hazards such as broken glass, broken toys or play equipment

  • c. Play equipment is anchored firmly in the ground (as necessary)

11. Transportation:

  • a. Transporting vehicle is covered by accident and liability insurance as required by State of Kansas Child Care Regulations

  • b. Driver is over 18 years of age with a valid driver's license

  • c. Appropriate individual restraints are used for each child transported

  • d. Parental release forms for each child

12. Water Safety - Check if Applicable

  • a. In-ground pool

  • b. Above ground pool with at least four feet above ground (steps are removed from the pool when it is not in use)

  • c. A five foot high fence separates the pool from the play area

  • d. Wading pool (water is changed daily)

  • Full Compliance

  • Violations attached

  • I certify that I have read and understand this completed form and that all information is true and correct. I understand that it is my responsibility to remain in compliance. I will notify the City when I discontinue child care or move from present address.

  • Signature of Provider:

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