CLEARANCE FOR LICENSING and RELEASE OF INFORMATION
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CONFIDENTIAL Licensing Specialist Anchorage Dept. of Health and Human Services
Instructions: See reverse side for information, regulations, and definitions. Each “individual having contact with children,” according to AMC 16.55.010, must complete a separate form.Last Name First Name Middle Name Name of Center or Home
Home address: Street City State Zip Home phone:
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Residency in Alaska: _____ Years ____Months Date of Birth: ______ Male Female
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Aliases, Maiden Name, Previous Married Name(s): Social Security #: Start Date at Center or Home:
Driver’s License #/State:
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1. Have you been previously licensed (such as for a home or foster care), registered, or approved to care for a child(ren)?
NO YES If yes, indicate city, state and type of care and dates of licensure:
2. Have you ever had a license to care for children revoked or denied in Alaska or any other state?
NO YES If yes, attach an explanation.
3. Have you ever been investigated for child abuse or neglect? NO YES If yes, attach an explanation.
4. Do you have a physical, health, mental health or behavioral problem that may be detrimental to the health, safety, or well-being of children? If you have a question regarding a problem, discuss it with your Licensing Specialist.
NO YES If yes, attach an explanation.
5. Do you have a domestic violence problem or an alcohol or other substance abuse problem that can be detrimental (pose a risk) to the health, safety or well-being of children? NO YES If yes, attach an explanation.
6. Have you been under indictment, charged by information or complaint, or convicted of a crime listed under “prohibited offenses” on the reverse of this form? NO YES If yes, attach an explanation.
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Complete the following for all “members of your household” [see reverse side for definition (5)]: (Attach additional page if necessary.)
First Name Last Name Date of Birth
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I have attached the following required documentation as applicable (please check):
1Interested Persons Report (IPR) 1Copy of TB clearance (licensed homes only)
1Fingerprint cards 1Copy of CPR and First Aid certification (if applicable) (homes only)
I authorize the licensing representative to review criminal justice, juvenile justice probation, protective service, and
licensing records and to share this information (except federal criminal justice records) with the applicant/administrator
and, if applicable, between the State Child Protection agency and the Anchorage Department of Health and Human
Services. I certify that the contents of this form and information provided with it are true, accurate, and complete. I
understand that this information may otherwise be confidential and that I am waiving that confidentiality and any claim I
may have with regard to release of these records. Note: A parent permission signature and date is required for individuals in contact with children who are under 18 years of age (unless emancipated), and the 16- or 17-year old must also sign and date it. Parents, please sign above or below your child.
Signature of Applicant or Individual in Contact with Children Date
SUBSCRIBED AND SWORN to before me: ______
Notary Public Date My Commission Expires
Records Check: (Agency Use Only) Initials Date
Protective Services Clearance: Yes No (Information Attached) ______
Previous Licensing Clearance: Yes No (Information Attached) ______
Criminal Justice Clearance: Yes No (Public Safety, Juvenile Justice, &/or INGENS Printouts) ______
Sex Offender Registry Clearance Yes No (Information Attached) ______
INFORMATION FOR PERSONS COMPLETING THIS FORM
Alaska Statute 47.35, State regulations, and AMC 16.55, the Municipal regulations for children’s facilities, require individuals in contact with children to be free from problems that can be detrimental (pose a risk) to children. This form summarizes information that is required for three background checks: criminal justice information, protective services involvement, and licensing or approved care history. A check is required under AMC 16.55.100 D.15. for “the business owner and for each individual having contact with children in a child care facility to the extent provided by law.”
A name-based criminal justice check and a fingerprint-based check are required. The name-based criminal justice information printout is required in addition to fingerprinting because it can be obtained while awaiting the results of the fingerprint-based check. A name-based check is immediate, whereas fingerprint-based information takes longer.
Child Care Facilities:
Administrators have responsibility for ensuring that persons in facilities are free from problems that may be a threat to children. This is accomplished in part by screening volunteers and employees carefully through the application process.
Under state and federal laws and regulations, child abuse or neglect and criminal justice records are confidential with the exception of use in an administrative or court hearing. The Clearance for Licensing and Release of Information form is treated as a confidential part of the licensing file.
AMC 16.55.010 Definitions:
(1) “caregiver” means any staff person, at least 18 years of age, whose duties in a facility include care and supervision of children, and who may be in the caregiver-to-child ratio.
(2) "child abuse or neglect" has the same meaning as in AS 47.17.290;
(3) "indictment" includes presentment or charging by information; and
(4) “individual having contact with children in a child care facility” means an individual who has the opportunity to gain access to a child care facility, a caregiver, a member of the household, or an individual residing in any part of the premises housing a child care facility. It does not include :
A. A parent of a child in care, unless the parent is a caregiver or a member of the administrator’s household;
B. A parent’s designee to drop off and pick up a child in care, unless the designee is a caregiver;
C. An official or individual providing support services to the child care facility or to a child in care for fewer than five hours a week, such as infant learning teacher, attendant for a child with special needs, licenser, fire marshal, or food services sponsor;
D. Delivery service personnel while in performance of their duties;
E. Installation, maintenance, and repair service personnel for a period of less than two weeks;
F. The occasional visit of an individual who has an ownership or management interest in the facility and who does not function as a caregiver;
G. An occasional guest in a child care facility, including persons who present a specialized program to children in the presence of approved caregivers;
H. An individual residing in any part of the premises housing a child care facility, if that individual has direct access from the individual’s residence to the child care facility, and the individual remains or intends to remain in the residence for less than 45 days, in total, in a calendar year, and is not a caregiver; and
I. An individual coming into incidental contact with children during an outing away from the child care facility.
(5) "member of the household" means an individual residing in any part of the premises housing a child care facility, if that individual has direct access from the individual’s residence to the child care facility and the individual remains or intends to remain in the residence for 45 days or more, in total, in a calendar year.
Prohibited offenses:
(1) Within the last 10 years, under indictment, charged by information or complaint, or convicted of a misdemeanor crime of assault, reckless endangerment, misconduct involving a controlled substance, or perjury, as defined in AS 11 or the laws of another jurisdiction (AMC 16.55.250 B.5.a.) OR
(2) At any time, under indictment, charged by information or complaint, or convicted for the following laws or similar laws of another jurisdiction: (AMC 16.55.250 B.5.b.)
i. An offense against the family and vulnerable adults under AS 11.51;
ii. Perjury under AS 11.56.200;
iii. A serious offense as defined in AS 12.62.900. A serious offense includes:
§ A felony offense;§ Sexual abuse of a minor in 1st – 4th degrees;
§ Indecent exposure in 1st or 2nd degree;
§ Endangering the welfare of a vulnerable adult in 1st or 2nd degree;
§ Prostitution;
§ Former AS 11.40.080, 11.40.110, 11.40.130, or 11.40.200 - 11.40.420 (crimes against morality and decency), if committed before 1/1/80. / § A crime involving domestic violence;
§ Incest;
§ Contributing to the delinquency of a minor;
§ Intentionally exposing one’s buttock or anus (a disorderly conduct);
§ Promoting prostitution in the 1st – 3rd degrees. / § Sexual assault in 1st – 4th degrees;
§ Unlawful exploitation of a minor;
§ Unlawful marrying;
§ Distribution of child pornography;
§ Former AS 11.15.120 or assault with intent to commit rape under former AS 11.15.160
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