STATE OF NEVADA BRIAN SANDOVAL Governor RICHARD WHITLEY, MS Director CODY PHINNEY Administrator TRACEY D. GREEN, MD Chief Medical Officer DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF PUBLIC AND BEHAVIORAL HEALTH BUREAU OF HEALTH CARE QUALITY AND COMPLIANCE Child Care Licensing Program 3811 W Charleston Blvd #210, Las Vegas, NV 89102 Phone: 702-486-3822 Fax: 702-486-6660 dpbh.nv.gov CONSENT AND RELEASE FORM FOR FINGERPRINTING AND CRIMINAL HISTORY REVIEW A clearance cannot be issued without this form. You must complete this form when originally hired and when changing facilities, being rehired, or obtaining a new background check. Your original background check should take place in the jurisdiction where you will be employed. A valid child care work card issued by one jurisdiction may be valid in another jurisdiction without another background check (please consult with law enforcement where you will be employed or call the Child Care Licensing). Child Care Licensing requires a new background check every five years. I, , understand that as an employee, applicant, licensee or resident of (FACILITY NAME) a child care facility, I am required to be fingerprinted and to undergo a criminal record review pursuant to NRS 432A.175. NAC 432A.200(4)(a) requires fingerprinting be completed and submitted within 24 HOURS after date of hire and every 5 years thereafter. I do hereby consent to be fingerprinted and agree to the following conditions and terms: 1. The fingerprints will be used to check the criminal history records of the Federal Bureau of Investigation (FBI), the Nevada Criminal History Repository, and the Child Abuse and Neglect System (CANS). 2. I hereby authorize the FBI, Nevada Criminal History Repository, and/or other local law enforcement agencies and Child Protective Services agencies to release criminal history information and CANS history to Child Care Licensing. 3. All information provided to Child Care Licensing is confidential, as relating to a third party or entity. 4. I hereby authorize the Nevada Criminal History Repository to retain a fingerprint card in the central repository's master file for the sole purpose of identifying same against subsequent disqualifying criminal arrest and I authorize the Nevada Criminal History Repository to release criminal history information to Child Care Licensing in accordance with dissemination restrictions as provided for in the Nevada Revised Statutes. 5. I may be suspended, terminated, or disqualified from employment and/or licensure based on the findings of the criminal record review consistent with applicable laws and regulations or on the findings of the Child Abuse and Neglect System. 6. I understand that I may review the challenge the accuracy of any and all criminal history records which are returned to the submitting agency, and that the proper forms and procedures will be furnished to me by the Nevada Department of Public Safety Records Bureau upon request. 7. This waiver and its authority is valid until such time as the applicant is no longer licensed and/or employed at a child care facility. 8. I hereby release from liability and promise to hold harmless under any and all causes of legal action, the State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my criminal history records search and provided information to the submitting agency for any statement(s), omission(s), or infringement(s) upon my current legal rights. I further release and promise to hold harmless and covenant not to sue any persons, firms, institutions, or agencies providing such information to the State of Nevada on the basis of their disclosures. I have signed this release voluntarily and of my own free will. Name of Nevada child care facility where you worked previously Last date worked at facility Public Health: Working for a Safer and Healthier Nevada American LegalNet, Inc. www.FormsWorkFlow.com Name of child care facility (where applying/employed): Telephone: City First State Zip Code Middle Staff Member (title): Facility address: Your name: Street Last Owner Maiden name, nickname, and other names used: Your position at the above facility is (please check): Cook Driver Resident Volunteer Director Other (position) Do you have any scars, marks or tattoos? (If yes, give location and description): Social Security Number: Are you a U.S. Citizen? Street address: Street City State Zip Code Yes No If not a U.S. citizen, what is your citizenship? Mailing address: Street City State Zip Code Home telephone: Eyes: Sex: Hair: Birth date: Height: Cell phone: Weight: Birthplace: Race: This form must be complete and accurate. Failure to comply may result in a rejected application. 1. Have you ever had a substantiation (validation) of child abuse and neglect? Yes No If yes, explain: Date of charge: 2. Do you have pending charges/warrants against you? Yes If yes, explain: No Dates of charges/warrants: 3. Check any of the following which apply, past or present (if additional space is needed use the back of this page): Conviction(s):Yes Arrest(s): Yes Charge(s): Yes Citation(s): Yes No No No No Date of conviction: Date of arrest: Date of charge: Date of citation: Reference NRS432.170 ­ Convictions which may prevent employment in child care. List all arrests, including other states, even if the charges were dropped or dismissed. Please attach a separate page if extra space is needed. DATE CHARGE ARRESTING AGENCY CITY/STATE DISPOSITION Public Health: Working for a Safer and Healthier Nevada American LegalNet, Inc. www.FormsWorkFlow.com I do hereby agree to the above stated conditions and terms and certify that the above information is true and correct. Signature: Date: Hire, Rehire or Renewal (circle one) Applicant My signature below indicates that I have reviewed the arrests shown above, if any. Signature: Director/Owner Date: _____ LAW ENFORCEMENT AGENCY: Witness: Date: Signature of Official Taking Prints Fingerprinting must be completed and submitted within 24 hours of hire and every 5 years thereafter. Make a copy of this form for your records and mail or fax to: State of Nevada ­ DPBH Attention: Background Investigations Child Care Licensing Program 3811 W. Charleston Blvd., Ste 210 Las Vegas, NV 89102 Fax: 702-486-6660 *Do not send fingerprint cards or money orders to this address. They will be mailed back to you* Public Health: Working for a Safer and Healthier Nevada American LegalNet, Inc. www.FormsWorkFlow.com