Initial Request Change Suspend / Terminate Date Effective: Date Effective: Date Effective
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Mentor Name: NA SSN & DOB: Address: Phone #: Email: Will the Mentor be the
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_7000_Forms/PPS7210.doc
AS THE SOUL FAMILY LEGAL PERMANENCY RESIDENTIAL CUSTODIAN: (initial each statement
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______I have received a copy of the PPS 6320, SOUL FAMILY LEGAL PERMANENCY Change Status Form
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_6000_Forms/PPS6302.doc
KANSAS DEPARTMENT OF SOCIAL AND REHABILITATION SERVICES
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Please address referrals or questions to the appropriate staff below
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72
Regulation 8 -- Change of Placement Purpose
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https://www.dcf.ks.gov/services/PPS/Documents/ICPCtrainingmanual.pdf
FCL 002 Rev 2/2019 Page 1 OF 1 KANSAS
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Initial application (new facility, move, or change of ownership
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CURRENT ADDRESS
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Street Address City State Zip
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/FCL_forms/FCL_002_Individual_Background_Check_Request.pdfView duplicates
Complete the section(s) regarding the change(s) you are reporting
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Change in the number of hours that child care is needed or used
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☐ Address Change
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What is your new address
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https://content.dcf.ks.gov/EES/KEESM/Forms/ES-1512.docxView duplicates
Acknowledgment of Referral / Change / Closure
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Address
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SECTION V Case Status Change
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☐ Court venue change (custody only / services transfer to another region
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☐ Family did not sign Family Case
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_4000_Forms/PPS4205.docx
Information: Name of Parent 1: Email Address: Cell Phone #: Name of Parent 2: Email Address: Cell Phone #: Street Address: City, State and Zip Code: County of
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_5000_Forms/PPS5318.doc
move to new state New Address: Child-only move to new state New Address: Reason: Family new phone/email New
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https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Section_9000_Forms/PPS9121.doc
KANSAS LAWS AND REGULATIONS FOR LICENSING RESIDENTIAL CENTERS AND GROUP BOARDING HOMES FOR CHILDREN AND YOUTH
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permit, and each licensee that wants the department to display the address
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https://www.dcf.ks.gov/services/PPS/FCL/Documents/Regulations GBH and Residential Centers 8.24.pdf
EES Program Administrators
September 22, 2011
Page 5 of 8
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M E M O R A N D U M
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SUBJECT: Implementation Instructions - KEESM Revision #49
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Potential Resources – See Summary of Changes item
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https://content.dcf.ks.gov/EES/KEESM/Implem_Memo/Implementation Memo Rev 49final_9-29-11.docxView duplicates