Please list any physical limitations that may affect your ability to care for children or perform services in a childcare facility (including chronic diseases, disabilities, etc.):

I certify, under penalty of law, that the information I have provided is complete and accurate. I authorize the release of any adult criminal or juvenile offense or any abuse registry records, or any information in the records, and any disclosures made in this form, to the agency at which I will be employed and to the Department of Human Services and any person or entity it may designate to assist in the review of my criminal/juvenile or abuse registry history

By signing this form, I am affirming that the above statements I have made are true and factual to the best of my knowledge; and I am granting permission for all persons, organizations, or agencies listed above to be contacted for information regarding my background. any information in the records, and any disclosures made in this form, to the agency at which I will be employed and to the Department of Human Services and any person or entity it may designate to assist in the review of my criminal/juvenile or abuse registry history