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Child Care Provider Registration Agreement Page 6 2.7 EMAIL ADDRESS You agree to acquire and maintain a current email address which is readily available to ADES and your clients. 2.8 FORMS TO BE COMPLETED AND RETURNED You shall complete and return, or supply to the Department, the following forms and documents before the Department can enter into an Agreement with you: 1. Signature Page completed, dated, and: a. if an individual, signed by the Provider; or, b if a legal entity, signed by an individual authorized to enter into the Agreement on behalf of the Provider; 2. Provider Rate Agreement (CC-214) reflecting current rates for age groups the facility is licensed to serve [see Attachment #4]; 3. Provider’s Child Care Operational Information form (CC-100) indicating accurate information of the services provided by the facility [see Attachment #5]; 4. Copy of any documentation you give to Clients indicating your policies including expulsion, ages served, rates, hours, days of operation, holidays observed, etc.; 5. Completed and signed W-9 with a valid IRS Tax Identification Number for the Provider, or Social Security number if the Provider is an individual [see Attachment #6]; 6. Completed and signed Direct Deposit Enrollment form (CCA-1140A) indicating the specific information on the Provider’s financial institution, account number, and routing number [see Attachment #3] 7. Copy of the Sign-In/Sign-Out Record form the Provider intends to utilize [see Attachment #11]; 8. Copy of the certificate of completion for the computer-based training, DECCA1104-Basic Billing for CCA Providers; 9. You shall provide verification of your license to operate by: a. Sending the Department a copy of your license to operate issued by the regulatory agency; or, b. If you have not yet received your license, you shall have the regulatory agency contact the Department to verbally confirm your licensure. Once you receive your license, you shall forward a copy to the Department; 10. Copies of the National Accreditation certificate and/or of the Quality First Three (3), Four (4) or Five (5) Star Rating approval issued by First Things First, if applicable; 11. Copy of the Provider’s Emergency Preparedness Plan; and, 12. Copy of the Provider’s Certificate of Liability Insurance (ACORD form). 3.0 PROVIDER: RIGHTS AND RESPONSIBILITIES 3.1 COMPLIANCE WITH APPLICABLE LAW 1. You agree to comply with all applicable federal, state and local laws, rules, regulations, standards, and executive orders without limitation to those designated within this Agreement and maintain all required licenses, certifications, approvals and permits. Any changes in the governing laws, rules and regulations during the term of this Agreement shall apply but do not require an amendment to this Agreement. 2. You must be licensed/certified by ADHS as a child care center or a child care group home under A.R.S. §36-897 et. seq. or A.R.S.§36-881 et. seq. and comply with all applicable ADHS administrative rules contained in A.A.C. Title 9, Chapters 3 and 5. Providers on Indian reservations, you shall comply with applicable tribal regulations and standards, and Providers on military bases/posts, you shall comply with applicable military regulations. CCA-1210B (4-16) – Arizona Department of Economic Security