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CLAY COUNTY SOCIAL SERVICES LICENSING REVIEW DAY CARE Name: License Class: Address: Phone: List all children and adults living/working in the dwelling: NAME DATE OF BIRTH Is your basement for day care? Yes No N/A Do you have an attached garage? Yes No N/A Do you have any firearms in your house Yes No N/A or on your property? Are there any pets in your home? Yes No N/A If yes, what are they? Do you carry Day Care Liability Yes No N/A Insurance? If yes, through which company? Liability limits? List the Day Care related training that you have taken in the past year. DATE NAME OF TRAINING NO. OF HOURS ---PAGE BREAK--- Does anyone work with you in your day care? Yes No N/A If yes, name: Who is your emergency substitute? Name: Address: Telephone: Since your last licensing visits, have Yes No N/A there been any changes or additions in your household membership? If yes, describe: Has anyone in the household received Yes No N/A treatment or counseling for alcohol or drug abuse/dependency since your last licensing visit? Has anyone in your household received any Yes No N/A other counseling or been in contact with a social service agency for any reason? Has anyone in your household been arrested, Yes No N/A charged or convicted of a felony or misdemeanor, or been involved with court services for any reason? Any Comments: Family Day Care Provider Date Family Day Care Co-Provider Date