Utah Department Of Health, Child Care Licensing Initial Cbs / Lis Consent And Release Of Liability For Child Care
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2Utah Department of Health, Child Care Licensing
Initial CBS / LIS Consent and Release of Liability for Child Care
(2.2 A7, 5/13)
INSTRUCTIONS: You must read and complete both sides of this form, in legible print in black ink or typed. Your form will not be accepted
unless all required information and signatures on both sides are provided. Incomplete applications cannot be processed and will be returned to you.
SECTION 1: INDIVIDUAL APPLICANT INFORMATION
____________________________
____________________
_________________
_________________________________________________
Legal Last Name
Legal First Name
Middle Name
Maiden Name & All Previous Married Names and/or Aliases
_____/_____/_____
____________________
_______________________________ _______________________________________________
Date of Birth
Gender (male or female)
Social Security Number
Driver’s License # and State
_________________________________________
_____________________
________
___________
_______________________________
Current Street Address
City
State
Zip Code
Area Code & Home Phone Number
Answer ALL of the following questions. Circle “yes” or “no” for each question.
Do you have any of the following on your adult or juvenile record:
Yes
No Any felony or misdemeanor A convictions, pending criminal charges, pleas in abeyance, or diversions? (If yes, you will not be
allowed to work in child care unless your record is first cleared or expunged.)
Yes
No Any misdemeanor B or C convictions, pending criminal charges, pleas in abeyance, or diversions?
Yes
No Are you currently awaiting trial on any pending criminal charges?
Yes
No Have you ever been investigated for abuse or neglect by the Utah Department of Human Services, Division of Child and Family
Services (Child Protective Services) that resulted in a supported finding of abuse or neglect?
Have you lived in Utah continuously for the past 5 years?
Yes
No If no, list the addresses where you have lived and for how long. Follow the instructions under “Fingerprints” on the back side
of this form. Attach additional pages if more address space is needed.
____________________________________________________
___________________________________
______/______
______/______
Address
City & State
From (month/year) To (month/year)
____________________________________________________
___________________________________
______/______
______/______
Address
City & State
From (month/year) To (month/year)
I have read both sides of this form in its entirety. I hereby authorize the Utah Department of Health to process this criminal history check according to
Utah Code 26-39-404. I authorize investigation of all statements contained herein and understand that misrepresentation or omission of facts may
result in denial of my application. The release of any and all information is authorized whether the same is of record or not. I do hereby release all
persons, firms, agencies, companies, groups, or institutions, whomsoever, from any damages of, or resulting from, furnishing such information to the
Department of Health. I SWEAR THE INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
_______________________________________________________________________________________________
_______/_______/_______
Applicant’s Signature (Do not fax this document. Original signature is required)
Date
_______________________________________________________________________________________________
_______/_______/_______
Parent / Guardian Signature (If Applicant is under 18 years of age)
Date
SECTION 2: PROVIDER / FACILITY INFORMATION Was this facility licensed or residentially certified after June 30, 2013? ___ Yes ___ No
__________________________________________________________________________________
____________________________________
Name of Child Care Program or Licensee (If different than Applicant’s Name)
Area Code & Business Phone Number
_______________________________________________________________________
_____________________________
_______________
Business Address
City
Zip Code
_______________________________________________________________________
_____________________________
_______________
Mailing Address (If different than Business Address)
City
Zip Code
Program Type (check one): ____ Center
____Out of School Program
____ Licensed Family ____ Residential Certificate
____ Hourly Center
_____________________________________________
__________________________________________________
______/______/______
Printed Name of Facility Representative
Signature of Facility Representative
Date
(Owner, Director, or Director Designee)
(Original signature is required)
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