IU
INDIANA CHILD SERVICES/NCWWI EDUCATION PROGRAMCRIMINAL HISTORY AND BACKGROUND CHECKTHIS PAGE WILL BE SUBMITTED TO THE DEPARTMENT OF CHILD SERVICES FOR ONLY THE APPLICANTS WHO ARE RECOMMENDED FOR PARTICIPATION IN THE INDIANA CHILD SERVICES NCWWI EDUCATION PROGRAM. THIS PAGE WILL BE DESTROYED FOR ALL APPLICANTS WHO ARE NOT RECOMMENDED FOR THE PROGRAM.Name: ________________________________________________________________________________LastFirstMiddleDate of Birth: ____/____/ 19_____ SSN: _______- ____ -________Anticipated month and year of graduation: ___________________________________________________Which region in Indiana are you willing to go to for employment with the Department of Child Services? _______ Anywhere. If not anywhere, please list the three (3) regions where you would be willing to work (see attached map):1._____________ 2.___________________ 3.__________________ Have you ever been convicted of violating any laws (omit minor traffic violations)? If yes, please list conviction(s), date(s), places(s), and an explanation and attach to this application. _______ Yes__________ NoHave you ever been substantiated or indicated for child abuse or neglect by the Department of Child Services or any other child protection agency? _______ Yes`__________NoIf yes, provide dates and an explanation and attach to this application.I understand that a CPS records check will be completed by the Department of Child Services to determine if my name is identified in the Central Client Index maintained by the Department of Child Services in accordance with IC 31-33-17-1 and its successor regulations.I understand that failure to consent to this CPS records check will disqualify me from acceptance into the Indiana Child Services Education Program.I further agree to complete a criminal history check as required by the Department of Child Services. If selected for this program I will comply with the process of submitting my fingerprints for an FBI check through the Indiana State Police.I further understand that, upon receipt of the results of the criminal history and background check, the university may disqualify me from the Indiana Child Services Education Program.____________________________________________ ______________Signature of Applicant Date ................
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