Background Investigation Unit (BIU)

DISCLAIMER: This form is processed by the administrative staff of First Baptist Church of Englewood/Silver State Baptist Youth Camp and sent to the Colorado Office of Early Childhood. This form is not sent directly to the Colorado office of Early Childhood.

Full Name*

First NameMiddle NameLast Name

Email*

example@example.com

Social Security*

Previous Names Ever Used including maiden, middle, nicknames, etc

Date of Birth (MM/DD/YYYY)*

Date

Sex (M, F, X)*

Race/Ethnicity White, Black, etc

Phone #*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Have you lived at your current address for 10 years or longer?*

YesNo

Ten years of residence history (including temporary residence) is required.

Previous Address

Street Address

Street Address Line 2

CityState

Zip Code

Move-In Date (Month, Year)

Date

Move-Out Date (Month, Year)

Date

PREVIOUS ADDRESS (extended)

Please record all addresses and move-in/move-out dates for last 10 years.

Are you currently married?*

YesNo

Have you ever been married? (meaning separated by divorce/death, etc.)*

YesNo

If you answered YES to any of the questions above, you MUST provide information for your current spouse/partner AND each former spouse/partner.

Spouse/Former Spouse Name

Spouse First NameMiddle Name (required) Last Name

Previous Names Ever Used including maiden, middle, nicknames, etc

Date of Birth (MM/DD/YYYY)

Date

Sex (M, F, X)

Race/Ethnicity White, Black, etc

Former Spouses (if applicable)

Please include Full name, DOB, Sex, & Race/Ethnicity

Do you have any children (including adult children, step children, etc)?*

YesNo

Have you ever had guardianship of children that are not your own biological children (e.g., foster children)?*

YesNo

Have you ever lived in a home with any other children not referenced above? (not referring to siblings)*

YesNo

If you answered YES to ANY of the questions above you must enter information about the child and the other parent below.

D.1 Enter each child's information below. This includes adult children. This includes foster children, etc.

	Child’s First Name	Middle Name (required)	Child’s Last Name	(MM/DD/YYYY)	(M, F, X)
1
2
3
4
5

Additional Children

Full name, DOB, Sex

D.2 Enter information for the other parent of the children listed above. This is the parent that is NOT you.

	Parent’s First Name	(Full Name)	Parent’s Last Name	(MM/DD/YYYY)	(M, F, X)
1
2
3
4

By signing below, I authorize the Colorado Department of Human Services (CDHS) to complete a search of child abuse and neglect reports. I confirm that the information I provided on this Trails child abuse/neglect background check request form is correct and accurate to the best of my ability. I understand that providing false or misleading information to the Colorado Department of Human Services could result in criminal prosecution. I am also releasing the results of the Trails background check to the agency/facility listed on this form. I understand that the results are ONLY sent to the agency/facility.

Signature (Parent/Guardian required if under 18)*

Date*

Date

Background Investigation Unit (BIU)

Section B: Person to be Checked (BIU Applicant) (REQUIRED)

Section C: Spouse/Partner/Former Spouse (REQUIRED)

Section D: Child Information (Includes Adult Children) (REQUIRED)

Signature of Person Being Checked –REQUIRED