Record Check Authorization Form - Department For Children And Families


Department for Children and Families / Child Development Division
Licensed Child Care Programs - RECORD CHECK AUTHORIZATION
Print the name of the Child Care program exactly as it appears on the License Certificate:
(Certificate Number)
(Name of the program on the License Certificate)
(Town of Program)
(Program Telephone #)
Circle position held: Director Head Teacher Teacher Assistant Aide Substitute
Cook Janitor
Other (please list): ______________________
Print: ______________________________
_______________________ _________________
(Last Name)
(First Name)
(Middle Name)
Print maiden name and all other last names used: ______________________________________
Social Security #: _______________________ Date of Birth: ______/_______/_______
 Male  Female
Place of Birth: __________________________
Employment Start Date: ____/_____/_____ Personal Contact Number: ___________________
Email: ____________________________________________________________________________
Have you ever been convicted or found by a court to have committed a felony, fraud, crime
of violence or unlawful sexual activity, and/or had abuse or neglect substantiated against
him/her? ____ Yes ____ No
If YES, give conviction description: (attach additional sheets as needed)
I understand that the Agency of Human Services may make necessary and reasonable investigations into
my personal references, including, but not limited to, criminal records maintained by the Vermont
Criminal Information Center (State Police) and the abuse and neglect records maintained by the Agency.
Furthermore, I understand that I have the right to appeal the accuracy of any information obtained from
the Vermont Criminal information Center by writing to: Vermont Criminal Information Center,
Department of Public Safety, 103 South Main Street, Waterbury, VT 05671-2101.
Signature: __________________________________ Date: ______________________
Keep a copy for your record.
Child Development Division
NOB 1 North - 280 State Drive
Waterbury, VT 05671-1040


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