Day Care Provider License Application - City of Moscow

(PLEASE PRINT OR TYPE)CITY OF MOSCOWDAY CARE LICENSE APPLICATIONName ________________________________________________________________________________________________LAST MIDDLE (MAIDEN) FIRSTPERMANENT Address _________________________________________________________________________________STREET CITY STATE ZIPCurrent Address________________________________________________________________________________________STREET CITY STATE ZIPHome Phone: ____________________________ Cell Phone: ________________________________Email: ______________________________________________ Social Security #________________________ Sex _____Date of Birth: ______________________ Place of Birth: _____________________________________________________EMPLOYMENT INFORMATION (This section must be completed by Applicant):Name of Day Care Facility: __________________________________________________________________________Owner/Manager’s Name: _____________________________________ Phone Number: __________________________My position: [ ] owner [ ] manager [ ] director [ ] partner [ ] employee [ ] other:_________________Date Employment Begins (or will begin) with above day care facility: ________________________________________EVERY RESIDENCE FOR THE PAST FIVE (5) YEARS immediately preceding the date of this ApplicationADDRESS CITY STATE ZIP Move-In Month and Year / andMove-Out Month and Year1.__________________________________________________________________________________/_______________2.__________________________________________________________________________________/_______________3.__________________________________________________________________________________/_______________4.__________________________________________________________________________________/_______________5.__________________________________________________________________________________/_______________Have you ever, anywhere or at any time, been convicted of, or had involvement with/in any crime or circumstancelisted in Moscow City Code Section 9-10-8 [ ] YES [ ] NOIf any of the above events occurred, you must answer “YES” regardless of subsequent court action resulting indismissal or expungement. Explain each event fully. Use supplemental paper if necessary.DATE OF EVENT PLACE OF EVENT OFFENSE RESULT________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2014 APPLICATION FOR DAY CARE PROVIDER LICENSE PAGE 1 OF 2

WAIVER AND AUTHORIZATION TO RELEASE INFORMATIONTO:State of Idaho Department of Health and WelfareI authorize you to furnish the CITY OF MOSCOW, IDAHO and its Police Department (hereinafter“CITY”) with any and all information you have concerning me, including information of aconfidential or privileged nature. Specifically, I authorize you to release any and all informationcontained in the Idaho State Adult Protection Registry, Idaho State Child Abuse Registry or in filesconcerning my involvement in a child protection referral. Your reply will be used to assist CITY indetermining my fitness to be licensed as a day care provider.I understand my rights under the Privacy Act of 1974, United States Code, Title 5, Section 552A andany other privacy rights granted me by law and specifically waive those rights, with theunderstanding that information furnished will be used by CITY to determine my fitness to be licensedas a day care provider.I hereby release you, your organization, CITY, its employees, agents, and representatives, and allothers from any liability or damage which may result from furnishing the information requested.A photocopy reproduction of this Waiver and Authorization shall be as valid as the original. Youmay retain this Waiver and Authorization in your files.Applicant’s Name (printed) : _____________________________________________________________Date of Birth: _____________________ Social Security Number: ________________________________________________________________________Applicant’s Signature__________________________DateSubscribed and sworn to before me this ________ day of ______________________________, 201____.___________________________________________________NOTARY PUBLIC in and for the State of IdahoResiding at ___________________________________My Commission Expires: ________________________[ ] No record found on Statewide Child Abuse Register[ ] Other: ________________________________________________State of IdahoAuthorized Signature ________________________________________Date: _____________________________________________________[ ] No record found on Statewide Adult Protection Register[ ] Other: ________________________________________________State of IdahoAuthorized Signature ________________________________________Date: _____________________________________________________WAIVER AND AUTHORIZATION TO RELEASE INFORMATION PAGE 1 OF 1