Arizona Department of Health Services
Division of Licensing Services
Bureau of Child Care Licensing
150 N. 18th Avenue, Suite 400
Phoenix, AZ 85007
Phone 602-364-2539
Fax 602-364-4768

ADHS LICENSING EMPOWER PROGRAM REGISTRATION FORM

If you have registered this CDC or SGH facility between January 2011 and the current date, you DO NOT need to fill out this form.  If you do not know if your facility is registered for the Empower Program, please contact your Licensing Surveyor.

* Indicates a required field

* Facility Name (please use the facility name on your license/certificate)

* Facility Address (Street Address)

* Facility City

* Facility Zip Code

* Contact Name (First Name Last Name)

* Contact Phone Number (###-###-####)

* Email Address

* Please enter the date the current license expires (or "Initial" for a new pending license)

Date 
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* License Number (example: “CDC-0000” or “SGH-0000”)

Any child care facility or group home provider may participate in the Empower 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 Program” guidelines. Licensee or certificate holder also understands that the “Empower Program” 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.

* Please enter the Name of Licensee/Certificate Holder

* Please enter today's date

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

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

Flagstaff/Northern Arizona:
Bureau of Child Care Licensing
2532 N 4th Street #352 (mail only)
Flagstaff, AZ 86004
Fax 602-364-4768

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