Delaware Health and Social Services
Division of Public Health
 
 
APPLICATION FOR PRESCRIBED PEDIATRIC EXTENDED CARE LICENSE 
 
FACILITY NAME 	________________________________________________________________________
						Print 
 
FACILITY ADDRESS _______________________________________________________________________
 						ADDRESS 1 
 
 		________________________________________________________________________
 						ADDRESS 2 
 

		______________________________________	_______________	________________
  				CITY			     STATE	    ZIP CODE 
 

ADMINISTRATOR __________________________________________________________________________ 
  						Print 
 
DIRECTOR OF NURSING  ___________________________________________________________________
		    				Print 

 		R.N. License #:__________________      Exp. Date:______________


MEDICAL DIRECTOR  ______________________________________________________________________
		    				Print 

 		M.D. License #:__________________      Exp. Date:______________
 

FACILITY CONTACT  ______________________________________________________________________
					   Print Name and Title

PHONE NUMBERS	___________________________________   __________________________________ 
 		      FACILITY PHONE NUMBER                  FACILITY FAX NUMBER  
 
  
 
FACILITY TYPE 			______ PRIVATE 		_______ NOT FOR PROFIT 
PLEASE CHECK ALL THAT APPLY 
				______ PUBLIC		_______ PROPRIETARY 
CURRENT ENROLLMENT:_______ 
 				OTHER:______________________________________
CAPACITY:_____________ 
  
  
ACCREDITED? 	______ YES	______ NO 
 
  
IF YES, NAME OF ACCREDITING ORGANIZATION AND ACCREDITATION EXPIRATION DATE: 
 
____________________________________________________________________________ 
				   Print  
 
 
 
Expiration Date of Child Care License Issued by the Department of Services for Children, 
Youth,and Their Families:__________________________ 
 

PLEASE ATTACH THE MOST CURRENT COPY OF THE FOLLOWING: 
 
1. 	A LIST SHOWING THE NAMES AND ADDRESSES OF EACH OFFICER, DIRECTOR, AND OWNER HAVING 
	TEN (10) PERCENT OR MORE INTEREST IN THE FACILITY.  ALSO ATTACH A LIST OF THE 
	NAMES AND ADDRESSES OF ADVISORY BOARD MEMBERS IF DIFFERENT FROM THE PRECEDING GROUP. 

2. 	ACCREDITING AGENCY(IES) CERTIFICATE(S) AND REPORT(S) 

3. 	CHILD CARE LICENSING SURVEY REPORT 

4. 	OTHER:	___________________________________________________________________
 
 		___________________________________________________________________
 
 
 
DAYS OF OPERATION:______________________________________________________________ 
                                             PRINT 
  
HOURS OF OPERATION:_____________________________________________________________ 
 

NAME OF PERSON COMPLETING THIS FORM:______________________________________________ 
                                                        Print 
 
 
 
                           SIGNATURE:______________________________________________ 
 
			       TITLE:______________________________________________ 
 
                                                 DATE:_____________________________ 
 
 
CHECKS SHOULD BE MADE PAYABLE TO:  DELAWARE DIVISION OF PUBLIC HEALTH 
 
 
 
INITIAL APPLICATION FEE:  $100.00

ANNUAL LICENSURE FEE:  $50.00
 
 
PLEASE COMPLETE AND RETURN APPLICATION WITH LICENSURE FEE AND ATTACHMENTS TO 
 
OFFICE  OF HEALTH FACILITIES LICENSING & CERTIFICATION 
 
2055 LIMESTONE ROAD 
 
SUITE 200 
 
WILMINGTON DE  19808 
 
 
12/05 



Prescribed Pediatric Extended Care Center Services and Employee Information 
 
 
Services Provided 

                              	
			   Does      Are the	Number	  Are the	Number	     Are services 	Total   
                           your      services  	of	  services	of	     provided by   	number of
			   company   provided   persons   provided by   contractors  both	        caregivers
                           provide   by	   	employed  contractors?	providing    employees    	in each
                           these     employees 	in each   		each	     and		service
			   services? of the 	service	  		service	     contractors?	
	                             agency?	
                           Yes No    Yes No		  Yes No		     Yes No 
  
Registered Nurse	     	 
Licensed Practical Nurse      
Physical Therapy             
Speech Therapy 
Audiology Services
Occupational Therapy 
Nutritional Services 
Social Services 
Aide
Child Life Specialist 
Developmentalist 
Physician 
Other (please list): 
  
Doc. No. 35-05-20/08/02/57