Child Day Care - Staff Application Fee Form Page 4
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128.
Yes
No
Have you ever applied for a foster care or adoption license in Connecticut or in any other
state? If yes, when and where? ___________________________________________________
Agency Name: _________________________________________________________________________________
Agency Address: _______________________________________________________________________________
Agency Telephone Number: ______________________________________________________________________
9.
Yes
No
Have you ever been licensed for foster care or adoption in Connecticut or in any other state?
If yes, when and where? _________________________________________________________
Agency Name: __________________________________________________________________________________
Agency Address: ________________________________________________________________________________
Agency Telephone Number: _______________________________________________________________________
10.
Yes
No
Have you ever been disciplined, terminated or put on probation from any position you held for
child care? If yes, please explain.
Facility Name: ________________________________________________________________________________
Facility Address: ______________________________________________________________________________
Facility Telephone Number: _____________________________________________________________________
11.
Yes
No
Have you ever been convicted of any crime (including motor vehicle) in Connecticut or any other
State?
If yes, please indicate when, where and what the conviction(s) was:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
12.
Yes
No
Do you have any known medical or emotional illness or disorder that would pose a risk to
children in care or would interfere with or jeopardize providing them with proper care?
If yes, please explain:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
13.
Yes
No
Do you take any medication(s) that would affect your ability to provide for the proper care of
children? If yes, please explain:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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