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CCA-1204A FORFF (4-16) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Child Care Administration Date: NOTIFICATION OF CHILD CARE EXPULSION This form is to be used by a child care provider to notify DES of disenrollment of a child from their child care setting. Instructions: Provider is required to provide documentation of the steps taken to prevent this expulsion. This form must be completed by the child care provider and emailed to a DES Resource Specialist. The DES Resource Specialist will contact the provider and the parent/guardian’s eligibility specialist to change the child care authorization. C h i l d

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E x p ulsion B P P R S O C P D D P P 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. • Ayuda gratuita con traducciones relacionadas con los servicios del DES está disponible a solicitud del cliente. CCA-1204A (4-16) – Page 50 Arizona Department of Economic Security