Olmsted County Social Services Consent Form - Olmsted County Child Care Licensing

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OLMSTED COUNTY CHILD CARE LICENSING
2117 CAMPUS DRIVE SE- SUITE 200
ROCHESTER, MN 55904-4744
OLMSTED COUNTY SOCIAL SERVICES CONSENT FORM
Minnesota licensing laws require that agencies must search for any criminal convictions or arrests involving all persons being licensed
or relicensed for child care as well as all others living in their home. In order for us to do so, the following consent form must be
completed and signed. Your child(ren) aged 13 to 18 must also sign. Children have the same rights as adults and should know that a
search is being conducted and that records relating to this, such as juvenile records, are being reviewed. Both you and your
child(ren)’s signatures are necessary in order for us to review files on minors. In order for us to complete the study the following consent
form must be completed and signed. You will be notified of the results of the background study within 15 working days from when we
receive this completed form. If you do not receive the results within 15 working days, please be advised that more time is required to
complete the background study.
I hereby give my permission to Olmsted County to receive the information below and any of my investigative, arrest, conviction, or
criminal history records from the Minnesota Bureau of Criminal Apprehension, county attorney, sheriff or local police department,
national criminal history record repositories, criminal and juvenile records of other states, other public or private social service agencies,
and juvenile, municipal, and district courts on any person living or working in the day care or foster care residence. I also give my
permission for Olmsted County to receive any information concerning these same individuals as related to findings of substantiated
abuse or neglect of vulnerable adults or maltreatment of minors and chemical dependency treatment. I understand that this information
is private data and will only be shared with staff or the consultants who may need my information to provide services. This consent will
expire one year from the date of my signature below.
1. NAME OF APPLICANT OR LICENSED CHILD CARE PROVIDER
(PLEASE PRINT CLEARLY)
Name:
PRINT CLEARLY
FAMILY OR LAST NAME
COMPLETE FIRST NAME (NO NICKNAME)
COMPLETE MIDDLE NAME
MAIDEN AND PREVIOUS MARRIED NAMES
Date of Birth:
/
/
Sex:
Race:
Today’s Date:
/
/
MONTH
DAY
YEAR
M OR F
WHITE / BLACK / ASIAN / NATIVE AMERICAN
MONTH
DAY
YEAR
Social Security No.:
-
-
Drivers License No.:
Current Home Address: _____________________________________________________________________________________________________
NUMBER AND STREET
_________________________________________________________________________________________________________________________
CITY
STATE
ZIP
COUNTY
Signature:
(Required)
2. SPOUSE OR CO-APPLICANT
(PLEASE PRINT CLEARLY)
Name:
PRINT CLEARLY
FAMILY OR LAST NAME
COMPLETE FIRST NAME (NO NICKNAME)
COMPLETE MIDDLE NAME
MAIDEN AND PREVIOUS MARRIED NAMES
Date of Birth:
/
/
Sex:
Race:
Today’s Date:
/
/
MONTH
DAY
YEAR
M OR F
WHITE / BLACK / ASIAN / NATIVE AMERICAN
MONTH
DAY
YEAR
Social Security No.:
-
-
Drivers License No.:
Signature:
(Required)
Please continue to next page
OFFICIAL USE ONLY
MNCIS Check:
Yes
No
Checked by: _________________
Date: ________
NOT A DISQUALIFIER:
BCA Check:
Yes
No
Checked by: _________________
Date: ________
NOT A DISQUALIFIER:
SSIS Check:
Yes
No
Checked by: _________________
Date: ________
NOT A DISQUALIFIER:
Substantiated VA Offender Information:
Yes
No
Did not check
Record Destroyed – Date __________
Page 1 of 2
Revised 5/11/16

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