CHILD ABUSE RECORD INFORMATION (CARI) CONSENT FORM

CHILD ABUSE RECORD INFORMATION (CARI) CONSENT FORM

STATE OF NEW JERSEY, DEPARTMENT OF CHILDREN AND FAMILIES, OFFICE OF LICENSING
CHILD CARE CENTER
Indicate Reason for CARI by Checking Appropriate Box:

New Center Renewing Center New Staff Member Hired at a Licensed Center (Not Renewing)
Date of Hire

Month Day Year
Please Check Only If You Are:

Sponsor (Owner) or Sponsor Representative
Print your full name (first, middle, last)
Previous name, maiden name or nicknames
Date of name change or date of marriage

Month Day Year
Date
Home address
City
State
Zip
Date of birth

Month Day Year
Race
Social Security number
Sex
NOTE: Pursuant to the Federal Privacy Act of 1974 (P.L. 93-579), the disclosure of your Social Security number is voluntary. Your Social Security number, race, date of birth, and sex will only be used for the purpose of conducting a Child Abuse Record Information background check as authorized by the State Child Care Center Licensing Law (N.J.S.A. 30:5B-1 to 15
Full names and birth dates of your children, if any, whether living with your or not

If none, check this box

Your previous addresses since 1990 and the dates you lived at each address:

Your previous addresses since 1990 and the dates you lived at each address:

If none, check this box

Your previous addresses since 1990 and the dates you lived at each address:

All persons completing this form must read the following and sign below:

I consent to have the Department of Children and Families conduct a Child Abuse Record Information check to determine whether an allegation of child abuse or neglect has been substantiated against me. I certify that I am not currently being investigated for any allegation of child abuse or neglect. I understand that if a record of substantiated child abuse or neglect is found, or if I refuse to sign this consent form, I will not be permitted to sponsor or work at this or any other licensed child care center in New Jersey. I certify that all information I have given on this form is accurate and complete to the best of my knowledge.
Signature

Clear
Date

Month Day Year
Should be Empty:

CHILD CARE CENTER