Authorization For Background Check Form printable pdf download

Authorization For Background Check Form

Illinois Department of Children and Family Services

AUTHORIZATION FOR BACKGROUND CHECK

Child Abuse and Neglect Tracking System (CANTS)

For Programs NOT Licensed by DCFS

NOTE: Do not use this form if you are an applicant for licensure or an employee/volunteer of a

licensed child care facility. Please contact your licensing representative.

Name: ________________________________________________________________________________

Last

First

Middle

Date of Birth: _____________

Gender (circle): Male

Female

Race: _________________

Current Address: _____________________________________________________________________

Street/Apt.

City: _____________________________ State: ___________________ Zipcode: ________________

Parish/School/Agency: _______________________________________________

Your Position (Circle One): Priest

Deacon

Religious Order

Lay Employee

Volunteer

List all addresses at which you have resided in the past five years:

List maiden name and/or all other names by which you have been known: (last, first, middle)

I hereby authorize the Illinois Department of Children and Family Services to conduct a search of the Child

Abuse and Neglect Tracking system (CANTS) to determine whether I have been a perpetrator of an

indicated incident of child abuse and/or neglect or involved in a pending investigation. I further consent to

the release of this information to the agency listed below.

______________________________________________________________________________________

Signature

Date

Archdiocese of Chicago (Agency Name)

Jan Slattery

(Contact Person)

P. O. Box 1979

(Address)

Chicago, IL 60690-1979 (City/State/Zip)

Mail this request to:

Department of Children and Family Services

406 E. Monroe – Station #30

Springfield, IL 62701

DCFS

Authorization For Background Check Form