STATE OF ILLINOIS

DEPARTMENT OF CHILDREN AND FAMILY SERVICES

INFORMATION ON PERSON EMPLOYED IN A CHILD CARE FACILITY*

Today's Date:

Example 01/01/2000

Your email address:

 

 

Full Name:   Date of Birth: Social Security:

                                                                                                                                                                                                 Example 01/01/2000                                   Example 123-45-6789

 

 

Address:   City:   State:   Zip:

 

Phone:

 

 

Employing Facility:   Address: 

 

Marital Status:   Employment:   Date Employed:

 

Position for which employed (Check appropriate item):   Other (Specify)

 

Previous Employment (Last ten years of employment)

From To Name and Address of Employer Type of Work and Title

 

 

Other Direct, Unpaid Experience with Children (Such as scout work, Sunday School teacher)

 

Report of reference on File (At least three character and/or business)

Name of Reference Address Relationship

Educational Background (Select the one item indicating highest grade completed)

Elementary Grade:   High School:  

Years of College (Undergraduate)   Years of Graduate Work:

 

College Degree (Specify)           

Graduate Degree (Specify)

                

Name of School, College or University last attended:

Other Special Training (Specify)

Evidence of Educational Achievement on File:   (Explain "No")

Physical Examination

Last Examination (Date):

Name and Address of Examining Physician:

 

Health Clearance Report on File?   (Explain "No")

 

Certification of Employment

I, the employer, or authorized official of the employing facility, do hereby certify that the above-named person is employed in the position indicated and that, to the best of my knowledge is qualified for the position indicated, and employment is in accordance with minimum prescribed by the Department of Children and Family Services.

Signed:

Title: