ADHS Licensing Empower Pack Registration Form

Arizona Department of Health Services
Division of Licensing Services
Office of Child Care Licensing
150 N. 18th Avenue, Suite 400
Phoenix, AZ 85007
Phone 602-364-3240
Fax 602-364-4768

ADHS LICENSING EMPOWER PACK REGISTRATION FORM

* Indicates a required field
*
Facility Name (please use the facility name on your license/certificate)
*
Facility Address
*
Facility City
*
Facility Zip Code
*
Contact Name
*
Contact Phone Number
Email Address
*
Date Current License Expires (or "Initial" for a new pending license)
License Number (example: “CDC-0000” or “SGH-0000”)
Any child care facility or group home provider may participate in the Empower Pack program, regardless of when the license or certificate is due for renewal. By completing and submitting this Registration Request Form, the licensee or certificate holder agrees to adhere to all “Empower Pack” guidelines. Licensee or certificate holder also understands that the “Empower Pack” discount to application fees will apply only for initial and renewal applications for license/certificate effective dates on or after January 1, 2010. The fee discount is available only as long as funding is available.

Phoenix:
Office of Child Care Licensing
150 N. 18th Ave., Suite 400
Phoenix, AZ 85007
Fax 602-364-4768

Tucson:
Office of Child Care Licensing
400 W. Congress, Suite 100
Tucson, AZ 85701
Fax 520-628-6537

Flagstaff:
Office of Child Care Licensing
1500 E. Cedar Ave., Suite 22
Flagstaff, AZ 86004
Fax 928-774-2830