Child Care Program Record Check Authorization Form

Is this record check form for a multi-site child care program?

How many child care program sites is this record check form intended for?

Enter the below information for each program. Please ensure all fields are complete and that you enter the program name and certificate/license numbers as they appear on the License Certificates.

Certificate/License Number

Enter N/A if you/your program is in applicant status.

Program Name

Name of the program on the License Certificate.

Town of Program

Program Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Position Start Date

MonthDayYear

Indicate position held

See the child care licensing regulations if you need additional help to determine which position applies.

Is this an initial record check with this program?

Is this record check for a 5 year renewal at this program?

Program Contact Email

example@example.com

Program 2-Certificate/License Number

Enter N/A if you/your program is in applicant status.

Program 2 Name

Name of the program on the License Certificate.

Town of Program 2

Program 2 - Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Position Start Date at Program 2

MonthDayYear

Indicate position held at Program 2

See the child care licensing regulations if you need additional help to determine which position applies.

Is this an initial record check with this program 2?

Is this record check for a 5 year renewal at program 2?

Program 2 Contact Email

example@example.com

Program 3- Certificate/License Number

Enter N/A if you/your program is in applicant status.

Program 3 Name

Name of the program on the License Certificate.

Town of Program 3

Program 3- Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Position Start Date at Program 3

MonthDayYear

Indicate position held at program 3

See the child care licensing regulations if you need additional help to determine which position applies.

Is this an initial record check with this program 3?

Is this record check for a 5 year renewal at program 3?

Program 3 Contact Email

example@example.com

Program 4 - Certificate/License Number

Enter N/A if you/your program is in applicant status.

Program 4 Name

Name of the program on the License Certificate.

Town of Program 4

Program 4 - Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Position Start Date at Program 4

MonthDayYear

Indicate position held at program 4

See the child care licensing regulations if you need additional help to determine which position applies.

Is this an initial record check request with this program 4?

Is this record check for a 5 year renewal at program 4?

Program 4 Contact Email

example@example.com

Legal Name

Legal First NameLegal Middle NameLegal Last Name

Maiden name and all other legal names used

If more than one, please separate by commas. Enter N/A if not applicable.

Date of Birth

MonthDayYear

Age

Gender

Current date

MonthDayYear

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Personal Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Place of Birth City/Town

Please enter the city/town you were born in. (ex. Berlin)

Place of Birth State

Please enter the State you were born in. (ex. Vermont)

Place of Birth Country

Please enter the country you were born in (ex. USA)

Social Security Number (SSN)

Only enter numbers.

Other than Vermont, have you lived in any other States, US Territories, or tribal lands?

In the last five years, list the States, US Territories, or tribal lands you have resided in?

If more than one, please separate by commas.

I have read the FBI disclaimer Statement at https://outside.vermont.gov/dept/DCF/Shared%20Documents/CDD/Licensing/FBI-Disclaimer-Statement.pdf, in the event I have to submit to fingerprinting.

**In order to submit this form you must select yes to having read the FBI Disclaimer Statement.**

I authorize the Department for Children and Families to perform an investigation, and examine records including, but not limited to, the abuse and neglect records maintained by the Department for Children and Families and the Adult Abuse Registry, and criminal records and registries maintained by or accessible to the Vermont Crime Information Center. I understand that my Social Security number is required to conduct background checks. Furthermore, I understand my information will be added to VCIC subscription service. I understand that I have the right to appeal the accuracy of any information obtained from the Vermont Crime Information Center by writing to: Vermont Crime Information Center, Department of Public Safety, 45 State Drive, Waterbury, VT 05671-1300.

Signature

Signature Date

MonthDayYear

Parent/Guardian Signature (if under 18):

Parent/Guardian Signature Date

MonthDayYear

Important! If you need a copy of this submission for your records, please click the Print button below before you click Submit. You will not receive an email copy of your submission, but you will receive confirmation of your submission.

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