Consent And Authorization For Release Of Information For Family Child Care Homes Form
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1Licensure Unit - Children’s Services Licensing
PO Box 94986 - Lincoln, NE 68509-4986
(Lincoln FAX (402) 471-7763)
(Omaha FAX (402) 595-1657)
CONSENT AND AUTHORIZATION FOR RELEASE OF INFORMATION
FOR FAMILY CHILD CARE HOMES I and II
The names of the applicant, child care provider, licensee, primary and secondary providers, substitutes, volunteers and/or helpers, and the
names of all household members age 13 and older must be checked against the Nebraska Child Abuse/Neglect Register AND the Nebraska
Adult Abuse and Neglect Central Registry (for age 18 and older).
The Department needs your consent to check name/s against the Nebraska Child Abuse/Neglect Register
and the Nebraska Adult Abuse and Neglect Central Registry.
I consent to have Nebraska Department of Health and Human Services 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 on this form. 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 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 household member, secondary provider, substitute and/or helper for
the Licensee/facility named at the bottom of this form, 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):
Date of Birth:
Applicant Signature
Signature Date
Print Parent/Guardian Name - Parent/Guardian Signature - Signature Date
ADDRESS HISTORY: Provide 20 years of address history OR address history from
CHILDREN: Full Names and Date of birth of own children.
age 13. Begin with current address, include Street, City, State, and Date
If you have no children, write NONE.
moved to and away from each address (mm/yy – mm/yy).
DATES
STREET ADDRESSES
CITY and STATE
FULL NAME
DATE OF BIRTH
DHHS/CSL Office Use Only
The following information is required and must be completed by the licensed child care provider:
Licensee/Facility Name:
Facility Phone #:
Child Care License #
Facility Street Address:
City/State/Zip:
This form is available online at
Revised 3-17--2014
previous version 5/13 should not be used
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