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COVID-19 Community-Based Organization Remote Learning Site Registration Form

Pursuant to NCGS 110-98.5, Remote Learning Facilities that have executed this attestation form and registered with the NC Department of Health and Human Services are not considered to be childcare and not subject to licensure.

You must complete this registration form in full if you are a Community-Based Organization (CBO) operating a North Carolina Remote Learning Site pursuant to NCGS 110-98.5 Care for School-Age Children During State of Emergency. A separate form must be submitted for each individual site you are operating. The North Carolina Department of Health and Human Services (NCDHHS) and the North Carolina Division of Child Development and Early Education (NCDCDEE) will maintain an inventory of all CBOs that have registered on the DCDEE website.

If your CBO needs documents or forms to assist with program, staff, and children records, please visit the Division of Child Development and Early Education’s website at this link to view sample documents.

* Required Fields

Site Information

1.

Business NCID Number: *

2.

Site Owner Name: *

3.

Site Name: *

4.

Site Mailing Address:

Street / P.O. Box*
City*
State*
Zip Code*

5.

Site Phone Number: *

6.

Owner Phone Number: *

7.

Location Address: *

Street*
City*
State*
Zip Code*
County*

8.

Site Contact Person (if different from applicant):

Email Address: *
Confirm Email Address: *
 
Phone Number:
Cell Phone Number:
Fax Number:

9.

Scheduled Days and Hours of Operation: *

*Monday
to
*Tuesday
to
 
*Wednesday
to
 
*Thursday
to
 
*Friday
to
 
*Saturday
to
 
*Sunday
to
 

10.

Date Site Began or Will Begin Operation: *


11.

Maximum Number of School-Age Children Planned to Serve by Age Range: *

 
Kindergarten – 3rd Grade: 
 
How many physical spaces (rooms) will serve this age group? 
 
How many adults will be supervising in each physical space (room)? 
 

4th – 5th Grade: 
 
How many physical spaces (rooms) will serve this age group? 
 
How many adults will be supervising in each physical space (room)? 
 

6th – 8th Grade: 
 
How many physical spaces (rooms) will serve this age group? 
 
How many adults will be supervising in each physical space (room)? 
 

9th – 12th Grade: 
 
How many physical spaces (rooms) will serve this age group? 
 
How many adults will be supervising in each physical space (room)? 

12.

Total number of staff working at Remote Learning Site: *

 
Full Time: * 
 
Part Time: * 

Staffing:

13.

* My site will ensure all staff complete a Criminal Background Check before working with children

 

14.

* My site will ensure the sex-offender registry is checked for all staff before working with children.

 

15.

The following trainings and certifications will be completed by all staff before they care for children:
 

16.

The following trainings will be completed by all staff within 30 days of caring for children:
 

Policies and Plans:

17.

* My site will adhere to guidelines in the StrongSchoolsNC Public Health Toolkit (K-12) including social distancing and minimizing exposure, wearing cloth face coverings, protecting vulnerable populations, coping and resilience, cleaning and hygiene, monitoring or symptoms, handling suspected, presumptive, or confirmed positive cases, communication, and combatting misinformation, checking water and ventilation systems.

18.

* My site will notify the local health department if any children or staff at the site tests positive for COVID-19.
 
Describe procedure for notifying health department if any children or staff at the site tests positive for COVID-19.
 

19.

* My site will notify staff and families in coordination with the local health department of confirmed positive COVID-19 cases, while maintaining confidentiality.

20.

* My site has an emergency and evacuation plan.
 
Describe emergency and evacuation plan:
 

21.

* My site has a communication plan to notify families in place in case of an emergency.
 
Describe emergency communication plan:
 

22.

* My site will have procedures for and documentation of child check in and check out. 
 
Describe check in and check out procedures:
 

Facilities:

23.

* How many bathrooms and handwashing sinks does my site have? 
 
Bathrooms:  *
 
Handwashing Sinks:  *

24.

* My Site has a Certificate of Occupancy that includes current building, fire, and sanitation inspections
 
 
 

 
 
 

 
 

25.

* My site will comply with applicable Americans with Disabilities (ADA) requirements

26.

* My site will have lockable hazardous products and medication storage.
 
Where will this lockable storage be located?
 

Insurance:

27.

* My site will have appropriate liability insurance. 

28.

* My site chooses to offer transportation.
 
If yes, my site will ensure transportation is licensed and insured.

Materials and Resources:

29.

* My site has adequate supplies including but not limited to: proper resources for conducting daily screenings and daily health checks; handwashing stations with soap and water; paper towels; EPA registered disinfectants that are active against coronaviruses; clean face coverings; and lined trash cans. 
 
Will your site provide face coverings for staff?  
 
Will your site provide face coverings for children?  
 
Will your site provide face coverings for visitors? 

30.

* My site has adequate resources to care for school-aged children (e.g. food, supplies, activities, internet access, tables, quiet space).
 
Describe food delivery and mealtime procedures (do parents pack meals, or does the program provide, how many children in an eating area at once, etc.):
 

31.

* My site will have available developmentally appropriate materials and activities for periods during the day when children may not be engaged in remote learning activities.
 
Describe a sample of activities and materials provided:
 

*I confirm that the answers on this form are truthful and complete; understand that my completed registration form, regardless of the answers provided, allows me to operate a North Carolina Remote Learning Facility pursuant to NCGS 110-98.5 Care for School-Age Children During State of Emergency; and further understand that the answers provided will be shared in full publicly.

 
 
 

Signature of Owner*

 
Date* Today is: 11/30/2020
 
 
ver: 1.1.20.215
 

 

 

2201 Mail Service Center | Raleigh, NC 27699-2200
919-814-6300 | 1-800-859-0829 (In State Only)

 
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