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This record shall be retained for a period of five (5) years after termination of the Agreement. Completion Instructions for CC-100 PROVIDER’S CHILD CARE OPERATIONAL INFORMATION A. Purpose. Registration for the provision of child care services is designed to provide demographic information and service delivery capability on the part of the provider and ensure payment for eligible child care services. The information will become a permanent part of the Child Care Provider Registration Agreement (Agreement) and Contract File if a registration agreement is awarded. It will also be used to input information in the computer. Therefore, accuracy in preparing this document is essential. ALL SECTIONS MUST BE COMPLETED. IF A SECTION DOES NOT APPLY, MARK “N/A,” (NOT APPLICABLE). B. Completion. Items not listed are self-explanatory. 1. FACILITY’S NAME – Enter the full business name of the facility. 6. OWNER’S FULL NAME – Enter the name of the owner(s) if sole proprietorship or partnership. If incorporated, enter the name of the corporation. If governed by a school district enter the school district’s name. If owned and operated by a church enter the church’s name. 7. DEPARTMENT OF HEALTH SERVICES (DHS) LICENSURE – Enter your DHS assigned CDC number (issued to a Child Care Center) or SGH number (issued to a Group Home), and license end date if presently licensed by DHS. 10. CORPORATION NAME OR SCHOOL DISTRICT NAME OR CHURCH NAME – If incorporated, enter the name of the corporation. If governed by a school district enter the school district’s name. If owned and operated by a church, enter the church’s name. 11. AREA CODE & PHONE NO. – Enter the phone number and fax number of the corporation, school district or church. 13. CONTACT PERSON’S FULL NAME AND TITLE FOR CHILD CARE ADMINISTRATION – Enter the name of the person the Contracts Unit can contact regarding contractual issues. 15. AGE RANGE OF CHILDREN TO BE SERVED BY YOUR FACILITY – Mark the age group of children that services will be provided for. Note: only mark the age group boxes DHS has licensed your facility to provide child care services for. 20. ARE YOU A *SECTARIAN ORGANIZATION OR SECTARIAN CHILD CARE PROVIDER – If the facility is owned and operated by a church organization, mark the “Yes” box, otherwise mark the “No” box. C. Routing. Original is placed in the contract file. The Canary copy is attached to the Agreement and forwarded to the provider for retention. D. Retention. Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact 602-542-4248; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Disponible en español en la oficina local. Page 43 CC-100 (3-12) – Arizona Department of Economic Security