Registered Home Census List Form - Vermont Department For Children And Families (Page 2 of 2) in pdf

Department for Children and Families / Child Development Division

Registered Home – RECORD CHECK AUTHORIZATION

All members of the household who are 16 years of age or older and/or any person(s) who assists in child care must read, complete, and

sign this

authorization.

This information will be used by the Division to make necessary and reasonable investigations

including,

but

not limited to, the child abuse and neglect records maintained by the Department and criminal records maintained by the Vermont

Criminal Information Center (State Police). The accuracy of any information obtained from the Vermont Criminal Information Center

may be appealed by writing to: Vermont Criminal Information Center, Department of Public Safety, 103 South Main Street, Waterbury,

Vermont 05671-2101.

Person applying for Registration / Re-Registration complete and sign this section.

Print name (last,

first,

middle)

Date of Birth

Social Security #



Print maiden and all other last names used

Male

Female

Place of Birth (Town & State)

Print town in which you live: _____________________________________

Telephone Number: ______________________

Have you ever been convicted or found by a court to have committed a felony, a fraud, a crime of violence or unlawful sexual

activity and/or had abuse or neglect substantiated against you? Yes____ No____

If YES, give conviction description: (attach additional sheets as needed)

___________________________________________________________________________________________________________________

I authorize the Department to perform an investigation, and examine records including, but not limited

to,

the child abuse and neglect

records maintained by the Department and criminal records maintained by the Vermont Criminal Information Center.

Signature:

Date:

•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

Others who live in your home who are 16 years or older, complete and sign this section.

Print name (last,

first,

middle)

Date of Birth

Social Security #



Print maiden and all other last names used

Male

Female

Place of Birth (Town & State)

Have you ever been convicted or found by a court to have committed a felony, a fraud, a crime of violence or unlawful sexual

activity and/or had abuse or neglect substantiated against you? Yes____ No____

If YES, give conviction description: (attach additional sheets as needed)

___________________________________________________________________________________________________________________

I authorize the Department to perform an investigation, and examine records including, but not limited

to,

the child abuse and neglect

records maintained by the Department and criminal records maintained by the Vermont Criminal Information Center.

Signature:

Date:

Others who assist in providing child care, but do not live in the home, complete and sign this section.

Print name (last,

first,

middle)

Date of Birth

Social Security #



Print maiden and all other last names used

Male

Female

Place of Birth (Town & State)

Print town in which you live

Telephone Number

Relationship to provider

Have you ever been convicted or found by a court to have committed a felony, a fraud, a crime of violence or unlawful sexual

activity and/or had abuse or neglect substantiated against you? Yes____ No____

If YES, give conviction description: (attach additional sheets as needed)

___________________________________________________________________________________________________________________

I authorize the Department to perform an investigation, and examine records including, but not limited

to,

the child abuse and neglect

records maintained by the Department and criminal records maintained by the Vermont Criminal Information Center.

Signature:

Date:

••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

Keep a copy for your record.

Child Development Division

NOB 1 North - 280 State Drive

Waterbury, VT 05671-1040

Registered Home Census List Form - Vermont Department For Children And Families Page 2

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