Olmsted County Social Services Consent Form - Olmsted County Child Care Licensing Page 2

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3. NAMES AND SIGNATURES OF ALL OTHER ADULTS AND/OR MINORS AGED 13 TO 18 LIVING IN THE HOME (NOT
INCLUDING CHILDREN OR ADULTS IN FOSTER CARE)
1. Name:
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)
2. Name:
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)
3. Name:
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)
4. Name:
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)
5. Name:
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 USE ADDITIONAL PAPER IF NEEDED”
Page 2 of 2
Revised 5/11/16

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