Cfs 718 - Authorization For Background Check For Child Care
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1
2CFS 718-B
Illinois Department of Children and Family Services
Rev 12/2015
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)*
Unlicensed Day Care Home
Child Care in the Home
*Parent/Guardian signature required
Unlicensed/Licensed/
Day Care Home
A
Member of Household (age 18 and over)
1
Applying for
Group Day Care Home
Employee/Volunteer
Ward
Applicant/Operator (Person applying to operate
Youth Emergency Shelter
Child Care Facility
Child Welfare Agency
a licensed child care facility)
(other than a home)
Group Home
Day Care Center
Executive Director
B
Exempt/Licensed/
Child Care Institution/Maternity Center
Day Care Agency
Employee/Volunteer
Applying for
License Exempt Facility
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
Date of Birth
Age
Place of Birth
Citizenship
Gender
Height
Weight
Hair
Eye
(Country)
(lbs.)
(color)
(color)
(Month/Date/Year)
(City and State)
Ft.
In.
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
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?
Yes
No
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 will not be processed without completion of this section. The licensing representative or child’s worker 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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