How to Apply

Fill out this form

Attach a copy of your ID

Attach a copy of last year’s tax return

Budget Class Required — Attache certificate of completion

Drop it off or mail to:
Central District Health Department
1137 South Locust Street
Grand Island, NE 68801

Your Information

Your Name: ____________________________________________________________

Home Address: _______________________________________________________

Phone Number: ____________________ Email: _________________________

I operate a licensed childcare? ☐ Yes ☐ No

If no, are you planning to obtain license within 12 months? ☐ Yes ☐ No

I agree to take the budgeting Class? ☐ Yes ☐ No

I agree to obtain 3 bids for any required updates needed? ☐ Yes ☐ No

Tell us what help you need at your childcare (check all that apply):

☐ Exit window ☐ Basement door ☐ Fence

☐ Sinks ☐ Smoke detectors ☐ GFI outlets

☐ Other: ___________________________________

Signature: ________________________________________

Date: ____________________