REOPENING REQUEST FORM

EARLY LEARNING SITE REOPENING REQUEST FORM
Program Type*

Type IType IIType IIIFamily Child Care ProviderIn-Home Provider
License Number*
TIPS Number
(If applicable)
Parish*
Center/Provider Name*
Email Address*
Center/Provider Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Center/Provider Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Section A:
Please check one of the following statements below:*

1. This center/home DID NOT sustain damage and was able to continue operation.2. This center/home DID sustain damage and will (or has) reopen(ed).3. This center/home DID sustain damage and WILL NOT REOPEN. Please close my center/home.
Expected Reopening Date:

MonthDayYear
NOTE: If reopen date changes, contact your Licensing Consultant.
Effective Closure Date:

MonthDayYear
Please include the effective date of closure.
Section B:

If you checked number 1 or 2 in Section A, please answer the following questions in regard to this center/home.
Are all utilities (water, sewages, electricity) currently operating normally?

YesNo
Was electricity off for more than 48 hours? (Note: If yes, it is your responsibility to destroy and dispose of any food or food items properly.)

YesNo
Did any flood water enter the center/home? (Note: If yes, it is your responsibility to destroy and properly dispose of any items that came into contact with flood waters.)

YesNo
Did the center/home sustain any major structural damage?

YesNo
If the center/home lost electricity, has electricity been restored by the electric company?

YesNoN/A
Is the center/home operating on generator power?

YesNo
Is the fire alarm system working?

YesNo
Are the smoke detectors working?

YesNo
Do you have a sprinkler system?

YesNo
If you have a sprinkler system, it is in working order?

YesNoN/A
Are the exits free and unobstructed?

YesNo
Are the exit doors in proper working condition?

YesNo
Section C:
I certify that this center/home has sufficient staff to meet child: staff ratios for all hours of operation; has the means to feed the children; is free of any hazards both inside and in the play area; and that the information above is true and correct. I understand that any false information provided above may lead to the revocation of the center’s license or termination of the provider’s certification.
Signature*

Clear
Date*

MonthDayYear
Date
NOTE: THIS FORM MUST BE COMPLETED AND SUBMITTED AS INDICATED ABOVE IN ORDER TO CONTINUE TO PROVIDE CARE FOR CHILDREN AS WELL AS SERVE CCAP FAMILIES AS APPLICABLE.
Please upload any relevant pictures:

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Should be Empty:

EARLY LEARNING SITE REOPENING REQUEST FORM

Section A:

Section B:

Section C: