Cfs 718-B Authorization For Background Checks For Child Care
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1
2CFS 718-B
Illinois Department of Children and Family Services
Rev 12/2014
AUTHORIZATION FOR BACKGROUND CHECK for Child Care
READ INSTRUCTIONS ON REVERSE SIDE AND PRINT ALL INFORMATION
CHECK ONE BOX IN EACH COLUMN IN EITHER ROW A or B:
Category of Facility
Specific Type of Application
Person in the Home/Facility
Applicant
Member of Household (ages 13 to 17)*
Child Care in the Home
Day Care Home
*Parent/Guardian signature required
A
1
Licensed/Applying for
Member of Household (age 18 and over)
Group Day Care Home
Employee/Volunteer
Ward
Applicant/Operator (Person applying to operate
Child Care Facility
Child Welfare Agency
Youth Emergency Shelter
a licensed child care facility)
(other than a home)
Day Care Center
Group Home
B
Executive Director
Licensed/Applying for
Day Care Agency
Child Care Institution/Maternity Center
Employee/Volunteer
PERSONAL INFORMATION (Please see additions instructions on the back page)
Last Name/First Name/Middle Initial
Social Security or ITIN Number
__ __ __ - __ __ - __ __ __ __
Maiden and/or Any Names Formerly Used (Last/First/Middle Initial)
List all previous addresses for the past five (5) years,
including those outside of Illinois.
Dates
(Street/Apt.#/City/County/State/Zip Code)
From/To
CURRENT ADDRESS, TELEPHONE (when applicable):
Street/Apt.#:
__ __
:
City:
State
2
__ __ __ __ __
Zip Code:
County:
( __ __ __ ) __ __ __ - __ __ __ __
Home Telephone
( __ __ __ ) __ __ __ - __ __ __ __
Cell Phone
Have you lived outside of Illinois in the past 3 years?
Yes
No
Citizenship
Date of Birth
Age
Place of Birth
Gender
Height
Weight
Hair
Eye
(Country)
(Month/Date/Year)
(City and State)
Ft.
In.
(lbs.)
(color)
(color)
USA
M
Other Specify
-
-
F
Ethnicity
Race (Check all that apply)
(see codes on Page 2)
Native American/Alaskan (Indian or Eskimo)
Black/African American
White
Declined to Identify
Asian
Native Hawaiian/Pacific Islander
Unknown
Could not be Verified
AUTHORIZATION /CERTIFICATION
Yes
No
Have you ever been indicated as perpetrator in a child abuse/neglect investigation?
Yes
No
Have you ever been convicted of a criminal offense, other than a minor traffic violation?
I certify that I have read and understood the Authorization/Certification box on the back page of this form.
3
SIGNATURE
DATE
Parent/Guardian Signature (if applicable)
DATE
TO BE COMPLETED BY SUPERVISING AGENCY
This authorization form will not be processed without completion of this section. The licensing representative must complete the following
Supervising Agency Name:
Date Fingerprinted:
Provider ID#
Full Name of Facility
Or
4
DCFS Region/Site/Field
Provider ID #
Street Address:
Name of Worker
Worker ID#/Phone Number
City
IL
ZIP:
Name of Supervisor
Supervisor ID#/Phone Number
BACKGROUND RESULTS AS APPLICABLE
FOR CENTRAL OFFICE OF LICENSING USE
Sex Offender Clearance:
SID#
Clear
Record
CANTS Clearance:
5
BC-03 Registered:
Illinois State Police Clearance:
FBI Sent Out:
FBI Clearance:
Transfer Clearances: SO/CANTS:
ISP:
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