Registration Type – Check at least one box from the left column for type of registration that best describes your worker category. If no other type applies,
select “Voluntary.” (A “voluntary registrant” is a person who is not mandated to register with the Family Care Safety Registry pursuant to §210.900 et seq., RSMo If you checked Long Term Care / Personal Care, please also make one or more selections from the column on the right for subcategory.
Social Security Number – You must provide your Social Security number pursuant to 19CSR 30-80.030(1 This identifying information, including Social
Security number, will be used for internal identification purposes and to conduct background screenings for the resource information listed in paragraph one above.
Personal Information – List your current Last Name, First Name, Middle Name, and any suffix associated with your last name. List any other names by
which you may have been known, including maiden names, past married names, and nicknames (attach additional sheets if needed For identification purposes, list your gender and date of birth.
Contact Information – List your address, city, state, ZIP code, and county. Include your telephone number and email address. We will use this information
to notify you of registration results and any background screenings conducted. Email notifications will be encrypted for improved security. To reduce postage costs, the Registry may contact you to request a personal email address if one is not provided.
Employer Associated with this Registration - If you are currently employed by or are seeking employment with a child care or long term care provider,
please list the facility name, address, telephone number, and contact person. If registration is not for employment purposes, make a selection from column on right. The employer entered in this section will not receive a copy of the registration notification. Employers eligible to use the Registry for caregiver screenings must make a separate request for your background information.
Registration Agreement – Sign and date the registration form. Your signature will authorize the Family Care Safety Registry to conduct the background
screening outlined in §210.903.2, RSMo and to provide the information to requesters for employment purposes, as provided in §210.921.1, RSMo.