Name: ___________________________________________________________________________________________________
Was the applicant a resident of the State of Florida within the past 5 years? YES
NO
Current Non-Florida Address:
__________________________________________________________________________________________________________
(Include city, state, and Zip Code)
P
revious Florida
Address:
________
____
___
____
___
__
_____
_____________________________FL_______________________ Dates: ________________
P
revious Florida Address:
________
____
___
____
___
__
_____
______________________________FL______________________ Dates: _________________
Employment Type:
Facility/Agency Name: ____________________________________________________________________________________
Address: _______________________________________________________________________________________________
Mailing Address City State Zip Code
Representative/Contact Name: _________________________________________________________
Phone: _____________________ Fax: _______________________ Email: ______________________________________
I understand it is a misdemeanor of the first degree for any agency to use or release abuse, neglect or abandonment information to
others. The information is CONFIDENTIAL and may be used only for the purpose for which it was obtained.
_____________________________________________________________ ________________
Printed Name and Signature of Requesting Facility/Agency Representative Date
Please return to DCF via email:
Attention: Child Welfare Record Request for Employment
Email: hqw.cwr.employment.requests@myflfamilies.com
Child Abuse History Record Request for
Child Care Personnel Employment
NOTE: This form MUST be submitted by the agency identified at the bottom of this page
The APPLICANT MAY NOT SUBMIT THIS FORM DIRECTLY to the Department of Children & Families
Only one applicant per release
(Please Print Clearly) Last
First
Middle
Full SSN: ____________________ DOB: _____________ Race: ______ Sex: ______ Prior Name(s), including Maiden: ________________________
TO BE COMPLETED BY THE APPLICANT
TO BE COMPLETED BY THE REQUESTING AGENCY
Expected Postition/Role of Applicant ___________________________________________
Other ___________________________________________
Day Care
_____________________________________________________________
Signature of Applicant
________________
Date
Group Home/Residential Care
In-Home Day Care
Pre-Kindergarten/Headstart
After School/Enrichment
B
y signing this form, I, as an applicant for employment in child care, authorize a search for reports of abuse, neglect, or abandonment investigated in
which my name appears and there were “verified findings” of maltreatment of a child(ren) and I am listed as the “Caregiver Responsible”. I understand I
will be given the opportunity to discuss the findings of the report(s). This consent is valid solely for the requesting employer/agency/facility listed below on
this form. (Chapter 39, F.S., Child Care and Development Block Grant Reauthorization, P.L. 113-186.)
Religious Exempt
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