Religious Organization Child Care Facility

Notice of Parental Responsibility

Facility Name Bolivar After School Enrichment___________________________________________________________________

Address (Street, City, State, Zip Code) 316 N. Main Ave. Bolivar, MO 65613________________________

INSPECTIONS

Section 210.211 RSMo exempts this religious organization child care facility from state licensing and supervision by the Department of Health and Senior Services (DHSS). It is state inspected only for fire, health and sanitation requirements as indicated below. Copies of the inspections are available.

NAME OF AGENCY AND TYPE OF VISIT	ADDRESS	TELEPHONE NUMBER	INSPECTION	DATE
Section for Child Care Regulation (Health and Safety Inspection)	PO Box 777 Springfield, MO 65801	417-895-6921	Pending Approved Not approved	10/31/09
Fire Marshal’s Office (Fire Safety Inspection)	PO Box 844 Jefferson City, MO 65102	417-732-2735	Pending Approved Not approved	10/19/09
Local Health Office or DHSS (Sanitation Inspection)	P.O. Box 124 , 1317 W. Broadway St., Bolivar, MO 65613	417-326-7250	Pending Approved Not approved	7/31/09

STANDARD STAFF/CHILD RATIOS ESTABLISHED BY THIS FACILITY STAFF/CHILD RATIOS FOR LICENSED CENTERS

AGE RANGE	NUMBER OF STAFF	NUMBER OF CHILDREN	AGE RANGE	NUMBER OF STAFF	NUMBER OF CHILDREN
Under 2 years of age	1 staff member for every	None	Under 2 years of age	1 staff member for every	4
2 to 4 years of age	1 staff member for every	None	2 years of age	1 staff member for every	8
			3 and 4 years of age	1 staff member for every	10
5 years of age and older	1 staff member for every	15	5 years of age and older	1 staff member for every	16

Total number of children enrolled by this facility _ 55___

BACKGROUND CHECKS: CHILD ABUSE/NEGLECT AND CRIMINAL RECORD(S)

Statute 210.254 RSMo requires the facility to conduct background checks for child abuse/neglect and criminal record reviews on each individual caregiver and all other personnel (who have contact with children in care) at the facility at the time of employment and every two years thereafter.

Background checks for child abuse and neglect through the Children’s Division (CD) and criminal record reviews through the Missouri State Highway Patrol have been conducted on each individual caregiver and all other personnel at the facility as required: Yes No

FACILITY DISCIPLINE AND EDUCATIONAL PHILOSOPHY/POLICIES

The disciplinary philosophy and policies of this facility are:

Discipline issues will be handled by the staff and director of the program. Logical consequences will be used when necessary. Discipline write-ups and parent conference will be scheduled as needed. Director and staff of the program hold the right to use correct restraining techniques when they perceive a child to be threatening to their own safety and/or others. The goal of restraining will be to remove the child from the situation and place them in a safer environment.

The education philosophy and policies of this facility are:

BASE is a ministry of FBC, designed to meet the needs of school age children in out of school time. We will provide quality care and enjoyable, age appropriate activities in a Christian environment.

REQUIRED SIGNATURES

Statute 210.254 RSMo requires the facility to furnish two copies of this document to a parent(s) upon enrollment of a child. Parents acknowledge by signature that they have read and accepted the information contained in this document. One copy of this signed document is given to the parent(s); the other copy is retained in the child’s record at the facility.

____________________________________________________________________________________________ __________________________________

PARENT(S) DATE

____________________________________________________________________________________________ __________________________________

PRINCIPAL OPERATING OFFICER/FACILITY DIRECTOR DATE

____________________________________________________________________________________________ __________________________________

INDIVIDUAL RESPONSIBLE FOR THE RELIGIOUS ORGANIZATION – PASTOR, MINISTER, PRIEST, ETC. DATE

Statute 210.254 RSMo requires a new facility to file a copy of the Notice of Parental Responsibility with the Bureau of Child Care at least five days prior to beginning operation. Each facility must file the Notice of Parental Responsibility annually during the month of August.

NOTIFICATION OF PARENTAL RESPONSIBILITY

Pursuant to section 210.254, RSMo Supp. 2000, the NPR will require:

"1) Notification that the child care facility is exempt as a religious organization from state licensing and therefore not inspected or supervised by the department of health and senior service other than as provided herein and that the facility has been inspected by those designated in section 210.252 and is complying with the fire, health and sanitation requirements of sections 210.252 to 210.257;

"2) The names, addresses and telephone numbers of agencies and authorities which inspect the facility for fire, health and safety and the date of the most recent inspection by each;

"3) The staff/child ratios for enrolled children under two years of age, for children ages two to four and for those five years of age and older as required by the department of health and senior services regulations in licensed facilities, the standard ratio of staff to number of children for each age level maintained in the exempt facility, and the total number of children to be enrolled by the facility;

"4) Notification that background checks have been conducted on each individual care giver and all other personnel at the facility. The background check shall be conducted upon employment and every two years thereafter on each individual caregiver and all other personnel at the facility. Such background check shall include a screening for child abuse or neglect through the division of family services, and a criminal record review through the Missouri highway patrol pursuant to section 43.540, RSMo. The fee for the criminal record review shall be limited to the actual costs incurred by the Missouri Highway Patrol in conducting such review not to exceed ten dollars;

"5) The disciplinary philosophy and policies of the child care facility; and

"6) The educational philosophy and policies of the child care facility."