MAAP Validation Visit Application

In order to receive a validation visit, the following form must be submitted by February 15.

*If you are applying for a Spring2018 visit, please complete the entire application. If you are applying for a Fall2018 or Spring 2019 visit, please check the correct box below and no other information is needed at this time.

**If you are already accredited, you must choose a Spring 2018 visit in order to avoid a lapse in your accreditation. Choosing a Fall 2018 or Spring 2019 visit will not extend your endorsement.

☐ Spring 2018Visit (April-May) ☐ Fall2018 Visit (Nov-Dec) ☐ Spring 2019 Visit (April-May)

School District
Program Name
Site Name
Site Street Address
City / State / Zip
Mailing Address
(if different from above)
City / State / Zip
Site Supervisor / Phone
Email Address
Program Coordinator / Phone
Email Address
Accreditation Coach
Address
City / State / Zip
Phone / Email Address
Select the term(s) that best describes your organization (continued on next page).
☐ / Private, not for profit
☐ / Private, for profit
☐ / Public School
☐ / Family Child Care
☐ / Faith-Based
☐ / Youth-Serving (i.e. YMCA, Boys & Girls Club etc.)
☐ / Parks & Recreation
☐ / Community Center
☐ / Military
☐ / College or University
☐ / Tribal
☐ / Other, please specify:
Please identify all funding sources you receive.
☐ / Tuition and fees
☐ / Grants and Donations
☐ / State Subsidies (e.g. CCAP)
☐ / Other, please specify:
Daily Start Time morning/mid-day/afternoon / a.m. / mid / p.m.
Time Program Closes morning/mid-day/afternoon / a.m. / mid / p.m.
How long has your program been in operation?
Does your program follow the Program Guide for School-Age Care Programs in Schools? / Yes / ☐ / No / ☐ / N/A / ☐ /
Is your program licensed with the Department of Human Services (DHS)? / Yes / ☐ / No / ☐ /
If yes, when does your current license period expire? MM/DD/YY
Is your program currently in good standing with DHS? / Yes / ☐ / No / ☐ / N/A / ☐ /
Is your program legally exempt from licensing? / Yes / ☐ / No / ☐ /
If yes, on what grounds is the program legally exempt? (i.e. school and/or district run program, single purpose program, number of school-age children served does not meet minimum threshold)
If your program is not licensed with the state of MN, how do you demonstrate that the program meets fire, safety and health codes?
Please check all applicable program components (included on next page).
☐ / After-School Care / ☐ / Before-School Care
☐ / Mid-Day / ☐ / 4-year-olds
☐ / Year-Round / ☐ / Summer
☐ / School Release/
Vacation Days / ☐ / Multi-Site
(include # of sites)
☐ / Other, please specify:
In the section below, please provide the number of children enrolled and average daily attendance for each age group.
Age Group / Number Enrolled / Average Daily Attendance
Pre-K
School-Age K-8
What is your average daily attendance? / a.m. / mid / p.m.
How many rooms are used by your program? / a.m. / mid / p.m.
Please name the rooms and how they are used.
(i.e. Gymnasium=large-motor activities, Cafeteria=Snack, etc.)
In the section below, please provide information relating to child to staffing ratios for all applicable program components throughout the programming day.
a.m. / Monday / Tuesday / Wednesday / Thursday / Friday
# of children
# of staff and initials
Midday / Monday / Tuesday / Wednesday / Thursday / Friday
# of children
# of staff and initials
p.m. / Monday / Tuesday / Wednesday / Thursday / Friday
# of children
# of staff and initials
Please select the term that best describes your program’s location. / In what type of facility is your program located?
☐ / Urban / ☐ / School – public, private or charter
☐ / Rural / ☐ / Community Center
☐ / Suburban / ☐ / Child Care Center
☐ / Religious Institution
Please provide a typical daily schedule for your program.
Please provide a narration about the unique qualities of your program.

MAAP Validation Visit Program Application

Signature/Verification Page

☐ Our program has fulfilled the goals of the devised program action plan and is ready for an accreditation validation visit.

☐ I understand that we must submit our Pre-Visit Documentation by March15th along with ourPre-Visit Documentation fee (see fee schedule on page 6 of the MAAP 2.0 Informational Guide).



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