CLARK COUNTY DEPARTMENT OF FAMILY SERVICES

NON-PRIMARY APPLICATION

PROVIDING NON-DIRECT CARE FOR FOSTER CARE AGENCIES

This application is for individuals 18 years or older, who live in a licensed foster home or regularly frequent the foster home. These individuals are not the primary caregivers and will at NO TIME be providing care or transportation to children. Young adults who are 18 years or older and still under court jurisdiction,DO NOT need to complete this application. This application is necessary to obtain DFS clearance.

Completed Application includes (copies of documents are acceptable):

  1. Application for Non-Primary Non-Direct Care – completed
  2. If applicant has any history of DFS Hotline complaints, provide explanations of each
  3. Contact DFS Records Dept at (702) 455-6683 to obtain records if necessary
  4. If applicant has any arrest history, provide the following:
  5. Written explanation from applicant
  6. Support letter from Agency
  7. Court disposition records
  8. Signed Release of Information
  9. Current NV Driver’s License or NV Identification Card
  10. TB Results
  11. Proof of Social Security number (may be card or other legal documents showing SS #)
  12. Five references, no more than 2 related and must have known applicant for at least 2 years
  13. Fingerprint Receipt

** PLEASE DO NOT INCLUDE ANY OTHER INFORMATION EXCEPT WHAT IS REQUESTED ABOVE.

Agency Non-Primary Cover Sheet / Agency:
Name: / Direct Care (ALL)
Foster Home Name: / Non-Direct (NO CPR/Training/Auto)
Application Received: / Assessed / UNITY
Date to Worker: / Intake Log Updated / Email to Agency
Date Completed / Other:
Adam Walsh (State: )
Fingerprinted
Scope
CANS
A.Arrest History (If yes, provide B, C, & D) / Yes No
B.Explanation from applicant / Yes No
C.Support letter from agency / Yes No
D.Provide final disposition / Yes No
Expiration Date
NV Driver’s License
TB Records
CPR
Auto Insurance
Social Security Card / Yes No
Training Hours / 40 20
Release of Information / Yes No
Degree/Diploma/Transcript (if applicable) / Yes No
Verifiable Experience (if applicable) / Yes No
Total Number of References: / Rel:
Non:
Full Clearance as of
Waiver Approval / Perm Letter Sent:
NAC 424.
NAC 424. / If Denied, Denial Letter sent via
Date Approved or Date Denied / Certified Mail on: //

CLARK COUNTY DEPARTMENT OF FAMILY SERVICES

NON-PRIMARY APPLICATION

PROVIDING NON-DIRECT CARE FOR FOSTER CARE AGENCIES

AGENCY NAME:

NAME OF PRIMARY FOSTER HOME (LICENSEE) APPLICANT IS APPLYING TO BE CLEARED FOR:

APPLICANT INFORMATION:

Last Name: First: Alias:

Address (physical):City: State: Zip Code:

Address (mailing): City: State: Zip Code:

Telephone: () -Alternate Telephone: () -

Date of Birth: Place of Birth - City: State:Country:

Social Security Number: --

: Number: Expiration Date:

Race: If American Indian or Alaskan Native, provide tribal name and member number:

Ethnicity:

Are you a US Citizen? PICK ONEYesNo

If you are not a US Citizen, are you a Legal Resident? PICK ONEYesNo If yes, provide your resident number:

What languages do you speak?

RESIDENCE:

List the addresses where you have resided the last five (5) years. Include the name of the county.

Street / City / State / Zip / County / Dates
From / To
to
to
to
to

REFERENCES: Please list five(5) references that have known you for at least two (2) years. No more than two (2) of the five(5)references may be relatives. Please be sure to include name and full mailing address including zip code. At least five (5) positive references are required for clearance.

Name / Relationship / Phone Number / Complete Mailing Address
(please include zip codes)
() -
() -
() -
() -
() -

TRANSPORTATION:

Non-primary applicants providing non-direct care may NOT provide transportation to counseling, medical appointments, visits with natural parents etc. Do you agree to abide by this statement?

BACKGROUND INFORMATION:

  1. Have you ever been licensed as a foster parentin Nevada or in another State or worked in a Foster/Group Home? If yes, complete the following:
  2. Name of agency in which you were licensed or worked:
  3. City, State of agency:
  4. Dates licensed or worked: From to
  1. Do you now or have you ever provided care for any child that is not your own?
  2. If yes, complete the following:

Relationship to Child / Where Care was Provided / Hours per Week Care was Provided / Dates Care was Provided
to
to
to
  1. Do you now or have you ever had a Child Day Care License?
  2. If yes, provide dates and location of Child Day Care License:
  3. License 1: From to in the state of
  4. License 2: From to in the state of
  5. If you hold a current child care license, please attach a copy of the license.
  1. Describe your general health (include any serious illnesses or disabilities):
  2. Do you have any history of mental illness, drug or alcohol addiction?
  3. If yes, explain:
  1. Are you or have you ever been on any medications? If yes, table below must be completed. Please exclude medications prescribed to treat common childhood illness such as flu, ear, infections, etc.

Medication
/

Dosage

/
Prescribed by
/

Date Started & Discontinued

to

to

to

  1. Have you ever been arrested, charged, and/or convicted of a crime?
  2. If yes, please provide the specific details, listing all ARRESTS, even if the charge(s) were later expunged or dismissed.
  3. Provide detailed descriptions and copies of all court documents verifying the final outcome of each event.

Date of Arrest
/
Nature of Arrest/Crime
/
Final Outcome
  1. Have you ever had Child Protective Services, Licensing or Child Welfare Agency involvement for allegations of child abuse and/or neglect?
  2. If yes, please complete the following:

Name of Household Member / Investigating Agency / Date of Investigation / City, State where Incident Occurred / Allegation / Outcome of Investigation

I attest that the above information is complete and true to the best of my knowledge. Failure to disclose or answer the questions truthfully may result in an immediate denial of this application.

Printed NameSignatureDate


CLARK COUNTY DEPARTMENT OF FAMILY SERVICES

RELEASE OF INFORMATION

Regarding:

Agency Name:

Applicant Name:

Social Security Number of Applicant: --

You are authorized by the undersigned to release to the Department of Family Services, the information including, but not limited to that indicated below. This authorization constitutes a full and complete release from any liability resulting from disclosure of such information. This authorization also permits release of medical information under the Drug Abuse Office and Treatment Act of 1972 (P.L. 92-255) and Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act amendments of 1974 (P.L. 93-282). A photocopy of this form shall be as valid as the original.

Data Requested (to be completed by Department of Family Services Representative):

______

Applicant SignatureDate

Non-Primary Application for Non-Direct Care Jan 2014 Page 1 of 6