Consent And Authorization For Release Of Information Form For Child Care Centers, Preschools And School-Age-Only Programs
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1Licensure Unit - Children’s Services Licensing
PO Box 94986 - Lincoln, NE 68509-4986
Fax: 402-471-7763
CONSENT AND AUTHORIZATION FOR RELEASE OF INFORMATION FORM
FOR CHILD CARE CENTERS, PRESCHOOLS AND SCHOOL-AGE-ONLY PROGRAMS
Child Care Center, Preschool and School-Age-Only personnel (applicant, licensee, director, regularly identified substitute, and staff including
teachers, assistant teachers and all support staff age 13 and older) listed on a license application for initial, renewal, and/or amendment licensure shall
be screened against the Nebraska Child Abuse and Neglect Register and the Nebraska Adult Abuse and Neglect Central Registry (age 18 and older)
by the Department BEFORE issuing a license. New candidates being considered for employment in a Child Care Center, Preschool and/or
School-Age-Only Center must be screened against the same Register/Registry BEFORE being hired.
Position applied for:
Employee Interview Date:
Volunteer Start Date:
Licensed Facility Name:
LICENSE#:
Address (mail):
Area Code/Phone Number:
City/State/Zip:
Area Code/Fax Number:
The department needs your consent to check your name/s against the Nebraska Child Abuse and Neglect Register
and the Nebraska Adult Abuse and Neglect Central Registry.
I give my consent to Nebraska Department of Health and Human Services to conduct Registry Checks of my name/s on the Registries listed above
AND authorize the release of the Registry Check results to the licensee/facility named above. The Department may state if my name appears or does
not appear on the registers as an alleged perpetrator and may use information obtained for licensing determinations.
Note: All persons under the age of nineteen years of age are minors; therefore, Releases completed by those individuals between the ages of 13 to 19
years of age must be signed by the minor AND by the Parent and/or Guardian of said minor. (In case any person under the age of nineteen years of
age is married, he/she is no longer a “minor” and the signature of the parent and/or guardian is not required.)
The submission of Social Security Numbers is voluntary; however, they are requested for the purpose of expediting the process of conducting the
required background checks. Social Security Numbers will not be released without the individual’s consent except as required by law. This
authorization is valid as long as the person is a director, teacher, assistant teacher, support staff, household member, substitute, volunteer and/or
helper for the child care facility and address named above, unless this authorization is revoked in writing.
***** INCOMPLETE RELEASES WILL NOT BE PROCESSED *****
Print Applicant Current Name (First, Middle, Last, Suffix (Jr/Sr/II/III):
Gender:
Applicant Social Security Number:
M
F
Print Other Names (Marriages/Maiden/Alias/Nicknames. If none write NONE):
Applicant Date of Birth:
Applicant Signature
Date of Signature:
Printed Name and Signature of Parent/Guardian of Minor
Date:
Provide 20 years of address history OR address history
Full Names and Date of Birth of own
ADDRESS HISTORY:
CHILDREN:
from age 13. Begin with current address, include Street, City, State, and Date
children. If you have no children, write NONE.
moved to and away from each address (mm/yy - mm/yy):
DATES
STREET ADDRESS
CITY & STATE
FULL NAME
DOB
DHHS/CSL Office Use Only
This form is available online at:
Revised 3-2014
previous version 5/13 should not be used
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