Required Forms


Home Child Care Facility Permit Application Process

There are three forms necessary to complete an application and be issued a Fairfax County Home Child Care Permit. (These instructions are also available in Korean.)

Form 1 of 3

You must complete a Home Child Care Facility Permit Application. Requires a fee. Download the application now in English or in Spanish (PDF) so you can follow the information below.

Section A: Applicant Information

Complete and sign the Home Child Care Facility Application.

You must pay the $14 application fee. The application fee is not refundable and must be sent in with the application. There is a $50.00 fee for any check returned for insufficient funds.

Section B: Household Children Information

List all children 13 years old or younger living in the home.

Complete all information. Use full names, including middle names. Do not use abbreviations, except for N/A if not applicable.

Section C: Request for Search of the Central Registry and Release of Information form. No Fee.

List yourself and all other adults and children 14 years old or older living in the home, or any other adults who may regularly come in contact with the children. Complete a Child Protective Services Request and Release of Information Form for each person listed in Section C. (See form #2)

Complete all information. Use full names, including middle names. Do not use abbreviations, except for N/A if not applicable.

IMPORTANT Section D: Criminal History Record Request. Requires a fee.

Virginia state law requires a criminal background check for each adult 18 years old or older living in the home, or any adult who may regularly come into contact with the children – including yourself, the applicant.

A $15 processing fee is required for each person needing a criminal history record request. The processing fee is non-refundable. There is a $50.00 fee for any check returned for insufficient funds.

You must resubmit a criminal background check for each adult every five years.

The criminal history record results for each person must be free of any barrier crimes.

Section E: Applicant’s Signature

Review your home child care facility application form. Make sure all information is entered.

Sign and date your home child care facility application form.

Form 2 of 3

You must complete a Child Protective services request and release of information form. Review the information from section C above. No fee required.

Download the CPS request form now so you can clearly follow the information below. Important: copy or print this as a two-sided form before completing your information. Only two-sided forms are accepted for processing.

A separate form must be completed for each person listed in Section C of the application. That includes yourself and all other adults and children 14 years old or older living in the home, or any other adults who may regularly come in contact with the children.

Complete all information. Use full names, including middle name. Do not use abbreviations, except for N/A if not applicable.

The back of this form must be notarized and signed in the presence of a notary.

Forms for children 14-17 years old must be signed by the child and the parent in the presence of a notary, and must be notarized.

Only the original form can be processed. Do not fax this form.

STOP

Review your home child care facility application form and make sure the names of each of these individuals is listed in section C of the home child care application.

Form 3 of 3

You must complete a Sworn Statement or Affirmation form. No fee required.

Download the form now in English or in Spanish (PDF) so you can clearly follow the information below. Virginia State Law requires a Sworn Statement or Affirmation form for each adult 18 years or older living in the home or any adult who may regularly come into contact with the children, including the applicant.

A separate form must be completed for each adult and include their signature.

Final Step

Include your payment for all applicable fees. The processing fees can be combined and paid in one check, money order or certified check. Payment should be made payable to the Office for Children. Mail your completed forms and payment to:

Fairfax County Office for Children
Division of Community Education and Provider Services
12011 Government Center Parkway, Suite 800
Fairfax, VA 22035-1102

 

Go back to: Apply for a Family Child Care Permit

 


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