Consent Form For Substitutes, Helpers And Employees Of Child Care Facilities
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2OLMSTED COUNTY CHILD CARE LICENSING
2117 CAMPUS DRIVE SE- SUITE 200
ROCHESTER, MN 55904
CONSENT FORM FOR SUBSTITUTES, HELPERS AND EMPLOYEES OF CHILD CARE FACILITIES
The Minnesota Human Services Licensing Act requires that a criminal background study must be conducted for all
individuals age 13 and over who reside in a home where a licensed program is provided, or any employees, contractors,
or volunteers who will have direct contact with persons served by the program. 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 Community Services 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. I also give my
permission for Olmsted County to receive any information 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 used to establish qualifications of individuals who are affiliated with licensed programs and
who have direct contact with children or adults in these programs. This consent will expire one year from the date of my
signature below.
CHILD CARE PROVIDER’S NAME: __________________________________________________________
PROVIDER’S SITE ADDRESS: ______________________________________________________________
EMPLOYEE’S NAME: _____________________________________________________________________
Last Name
Complete First Name (No Nicknames)
Complete Middle
Maiden/Previous Married Name
DATE EMPLOYED: ____________________________
DRIVERS LICENSE NO. ____________________
BIRTHDATE: _____/_____/_____
SEX: _____
RACE: _____
SOC. SEC. _____/____/_____
Month
Day
Year
M/F
White/Black/Native American/Asian
SIGNATURE: ________________________________________
DATE: __________________________
CURRENT HOME ADDRESS: ______________________________________________________________
Number and Street
________________________________________________________________________________________
City
State
Zip
___________________________________________
_________________________________________
County
Telephone Number
List all your out-of-county addresses during the past 5 years on page 2 of this form
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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