REOPENING REQUEST FORM

EARLY LEARNING SITE REOPENING REQUEST FORM
Program Type
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.Format: (000) 000-0000.
Section A:
Please check one of the following statements below:
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?
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.)
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.)
Did the center/home sustain any major structural damage?
If the center/home lost electricity, has electricity been restored by the electric company?
Is the center/home operating on generator power?
Is the fire alarm system working?
Are the smoke detectors working?
Do you have a sprinkler system?
If you have a sprinkler system, it is in working order?
Are the exits free and unobstructed?
Are the exit doors in proper working condition?
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:

Cancelof
Should be Empty:

EARLY LEARNING SITE REOPENING REQUEST FORM

Section A:

Section B:

Section C: