Authorization for Background Check for Child Care Instructions

Please provide the current age of the applicant.

Please provide your last name.

Please provide your first name.

Please provide your middle initial.

Enter the three-digit area code for the cell phone number.

Enter the three-digit prefix for the cell phone number.

Enter the four-digit line number for the cell phone number.

Check this box if the individual is a citizen of the United States of America.

Check this box if the individual is a citizen of a country other than the United States and specify the country.

Please specify your country of citizenship if it is not USA. Fill only if 'Other Specify' is 'Yes'.

Check this box if you have been convicted of a criminal offense, other than a minor traffic violation.

Check this box if you have not been convicted of a criminal offense, other than a minor traffic violation.

Please provide the full street address, including apartment or unit number if applicable.

Please provide the current city of residence.

Please provide the current state of residence.

Please provide the current zip code.

Please provide the current county of residence.

Please provide the month of birth.

Please provide the day of birth.

Please provide the year of birth.

Please provide the ethnicity code as referenced on Page 2 of the form.

Please enter the starting date for your fifth previous address. Fill only if 'Yes' is 'Yes'.

Please enter the ending date for your fifth previous address. Fill only if 'Yes' is 'Yes'.

Please provide the complete street address, including apartment or suite number, city, county, state, and zip code for your first previous address. Fill only if 'Yes' is 'Yes'.

Please provide the 'From' and 'To' dates indicating the period you resided at the first previous address. Fill only if 'Yes' is 'Yes'.

Please provide the first previously used name, including the last name, first name, and middle initial.

Please provide the second previously used name, including the last name, first name, and middle initial.

Please provide the complete street address, including apartment number, city, county, state, and zip code for your fourth previous address. Fill only if 'Yes' is 'Yes'.

Please provide the 'From' and 'To' dates for your fourth previous address. Fill only if 'Yes' is 'Yes'.

Check this box if the individual identifies as male.

Check this box if the individual identifies as female.

Enter the last name of the individual to be printed.

Enter the first name of the individual to be printed.

Enter the middle initial of the individual to be printed.

Enter the provider identification number to be printed.

Please enter the three-digit area code for the home telephone number.

Please enter the three-digit prefix for the home telephone number.

Please enter the four-digit line number for the home telephone number.

Check this box if the application is for a License-Exempt Facility.

Check this box if the applicant is a Director or Operator of the facility.

Check this box if the applicant is an Employee, Volunteer, or Conditional Employee of the facility.

Check this box if you have ever been indicated as a perpetrator in a child abuse or neglect investigation.

Check this box if you have never been indicated as a perpetrator in a child abuse or neglect investigation.

Enter the height in inches.

Enter the weight in pounds.

Enter the natural hair color.

Enter the natural eye color.

Provide the city and state where you were born.

Check this box if you have lived outside of Illinois in the past 5 years.

Check this box if you have not lived outside of Illinois in the past 5 years.

Enter the last name of the individual.

Enter the first name of the individual.

Enter the middle initial of the individual.

Please provide the unique identification number or code assigned to the provider.

Check this box if you identify as Native American/Alaskan (Indian or Eskimo).

Check this box if you identify as Asian.

Check this box if you identify as Black/African American.

Check this box if you identify as Native Hawaiian/Pacific Islander.

Check this box if you identify as White.

Check this box if your race is unknown.

Check this box if you decline to identify your race.

Check this box if your race could not be verified.

Please provide the full street address, including apartment number, city, county, state, and zip code for the second previous address. Fill only if 'Yes' is 'Yes'.

Please provide the start and end dates you resided at the second previous address. Fill only if 'Yes' is 'Yes'.

Enter the first three digits of your Social Security or ITIN Number.

Enter the middle two and last four digits of your Social Security or ITIN Number.

Please provide the third previous street address, including apartment number, city, county, state, and zip code. Fill only if 'Yes' is 'Yes'.

Please provide the start and end dates for the third previous address in a 'From/To' format. Fill only if 'Yes' is 'Yes'.

Check this box if the application is for an Unlicensed Day Care Provider, meaning child care is provided in a home setting, whether at the child's residence/placement or the provider's home.

Check this box if the individual is a non-related child care provider.

Check this box if the individual is a non-related household member who is between 13 and 17 years old, requiring a background check with parent/guardian signature.

Check this box if the individual is a non-related household member who is 18 years of age or older, requiring a background check.