DCF Form (espanol)

1Attestation

2Child Care Experience

3Your Information

NOTE: This form must be completed by each employee or volunteer of a childcare facility, Care 4 Kids youth camp, and each member of a family child care provider’s home who is 16 years of age or older before a background check may be processed by OEC.

Legal Name*

First Middle Last

Attestation*

I do hereby authorize the Connecticut Department of Children and Families (DCF) to research their records for any and all information concerning charges, findings, dispositions, etc., relating to child abuse and/or neglect, in which I have been named, and to release this information in whole to the Office of Early Childhood (OEC) for the purpose of completing a comprehensive background check. I further authorize the OEC to release any final DCF substantiations of abuse or neglect which resulted in my placement on the central registry to the Director/Operator or other designee of a child care facility for purposes of determining my eligibility for employment, OR assessing my household environment based on an individual 16 years of age or older who resides in my household that is used as a family child care home. I release the DCF and OEC from all liability for any damages I may incur, which may result from the release or use of this information. I submit the information below to assist DCF in their research. This release is valid for a term of five years from the date of signature unless rescinded in writing.

I do hereby authorize

Within the last 180 days*

I was employed in a child care facility

I resided in a family child care home

I have not been employed in a child care facility or resided in a family child care home

Name of Family Provider, Center or Camp*

Your Role*

Center (Staff / Volunteer / Prospective)

Family Provider / Staff / Volunteer

Family Household Member

Group Home (Staff / Volunteer / Prospective)

Unlicensed Care 4 Kids Provider

Please provide the license number for the program where you are currently employed/volunteer or will be employed/volunteer

Please provide the license number for the family child care home

License Number*

Your Date of Birth*

Gender

Female

Male

Your Telephone Number*

Other names you have used

(maiden, married, nickname, etc.)

Your Email*

Your Current Address*

Street Address City State / Province / Region ZIP / Postal Code

Hidden

Your Current Full Address*

Have you lived at this address for the last 5 years*

Yes

Date you started living at this address*

Your previous residence(s) for the last 5 years*

Please list your previous addresses starting with your most recent previous address first. You need to ensure you account for the last 5 years. Use the + sign to add additional residences.

Number and Street

City

State

Zip

Start Date

End Date

Example of Residence for the last 5 years

Number and Street	City	State	Zip	Start Date	End Date
1455 Nathan Hale Blvd	Newington	CT	06111	Aug 2017	Aug 2018
125 Juniper Berry Lane	Hebron	CT	06248	Jan 2016	Aug 2017
247 125th St	Hartford	CT	06106	Oct 2011	Jan 2016

Authorization for Release of Information from DCF (Dec 2021)