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DCF Authorization Form
Child Care Experience
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.
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 This release is valid for a term of five years from the date of signature unless rescinded in writing.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 Date of Birth
MM slash DD slash YYYY
Your Telephone Number
Other names you have used
(maiden, married, nickname, etc.)
Your residence for the last 5 years
Please list your present address first with an end date of "current" and use the + sign to add additional residences.
Number and Street
Example of Residence for the last 5 years
Number and Street
1455 Nathan Hale Blvd
125 Juniper Berry Lane
247 125th St