First Name

Last Name

Phone

Email *

DCF Agency Name

DCF Agency Attention

DCF Agency Address

DCF Agency City

DCF Agency State

DCF Agency ZIP

DCF Applicant Middle Name

DCF Applicant Current Address

DCF Applicant Apartment

DCF Applicant City *

DCF Applicant State *

DCF Applicant ZIP *

DCF Current Address Start Date

DCF Previous Addresses Last Five Years

DCF Other Names Used

DCF All Children Biological Step

DCF Applicant Signature Date *

Signature

Clear

DCF Authorization and Release

I, the applicant named above, do hereby authorize the Department of Children and Families to research its records and if applicable request out of state checks, to determine whether or not I am on the central registry of persons responsible for child abuse and neglect. I understand that this information may be used to determine my suitability for the purpose selected above. I release the Department of Children and Families from any liability for any damages I may incur because of the release/use of this information.

DCF 180-Day Expiration

This authorization will expire 180 days after the date of the signature

DCF Portal Submission Requirement

Submit at https://portal.dcf.ct.gov/Portal/Main/#dashboard. To enroll your agency in the portal, please contact [email protected]. For questions or support, please contact the Background Check Unit at [email protected].

DCF CPS Authorization and Release Acknowledgement

I, (Applicant Name): ________________________________, do hereby authorize the Department of Children and Families to research its records and if applicable request out of state checks, to determine whether or not I am on the central registry of persons responsible for child abuse and neglect. I understand that this information may be used to determine my suitability for (check one): Employment Day Care Volunteer Intern Mentor Other. I release the Department of Children and Families from any liability for any damages I may incur because of the release/use of this information.

I consent to receive non-marketing text messages from CT ABA Services LLC regarding my DCF background authorization, required documents, submission status, employment or volunteer onboarding, and related follow-up. Message frequency may vary. Message & data rates may apply. Reply STOP to opt out or HELP for help.

I consent to receive occasional marketing and promotional text messages from CT ABA Services LLC regarding career opportunities, recruiting events, programs, and other CT ABA Services updates. Message frequency may vary. Message & data rates may apply. Reply STOP to opt out or HELP for help.