CLARK COUNTY DEPARTMENT OF FAMILY SERVICES

APPLICATION FOR AGENCY STAFF/NON-PRIMARY

This application is for foster care agency staff applying for clearance to work or for non-primaries
applying for clearance in a licensed foster home. The application questions and requirements differ
depending on the applicants role so please only fill out the required sections.

Completed Application includes (copies of documents are acceptable):

1. Cover Sheet fill in dates and information
2. Application for Agency Staff/Non-Primary complete all sections as applicable
a. If applicant has any history of DFS Hotline complaints, provide explanations of each. Copies
of reports do not need to be submitted and are only needed if applicant cant recall history.
i. Contact DFS Records Dept at (702) 455-6683 to obtain records if necessary
b. If applicant has any arrest history regardless of disposition, provide the following:
i. Written explanation from applicant
ii. Court disposition records
3. Signed Release of Information
4. NV Drivers License or NV Identification Card if non-driverclear copy to show face
5. Copy of Social Security card
6. Training Log (for direct care applicants only)Include completion certificates for online training
7. Degree/Diploma/Transcripts (if applicable)
8. Proof of verifiable experience (if applicable)
9. TB test results
10. CPR card--Adult, Child and Infant CPR (for direct care applicants only) **cannot be from an online
course
11. Proof of valid and current automobile insurance for any applicant who will drive children(if
applicant is only going to drive an agency vehicle, need to indicate this on application)
12. Five (5) references, no more than 2 related and all must have known applicant for at least 2 years
13. Fingerprint Receipt showing applicant printed for specific agency
14. **If applying as a new house parent, please also include a completed home study and fill out just the
cover sheet from the new Staffed Foster Home application

Agency Staff/Non-Primary Application Packet March 2017 Page 1 of 6

 Agency Staff/ Non-Primary Cover Sheet Agency:
Name: Direct Care Non-Direct Care
Staff Position (for Agency Staff) /
Foster Home Applying for (for Non-Primaries): Live In Non-Live In

Date Completed
(DFS staff to enter)
Other:
Adam Walsh (State: )

Fingerprinted
Scope

CANS
A. Arrest History (If yes, provide B & C) Yes No
B. Explanation from applicant Yes No
C. Provide final disposition Yes No

Expiration Date
NV Drivers License or ID Card
TB Test Due Date
CPR Due Date DFS staff to enter
Auto Insurance Exp Date
Provisional Clearance
(Minimum requirements: Application + 5 Pos
Social Security Card Yes No References + Fingerprints)
Training Log 40 20 Provisional given as of
Release of Information Yes No No (Did not qualify at time of assessment)
Degree/Diploma/Transcript (if applicable) Yes No No due to background issues
Verifiable Experience (if applicable) Yes No
Rel:
Total Number of References:
Non:
Full Clearance as of
*For Non-Direct Care applicants, no training log,
Perm Letter Sent:
CPR or auto insurance is required

If Denied, Denial Letter sent via

Certified Mail on: //

CLARK COUNTY DEPARTMENT OF FAMILY SERVICES

Agency Staff/Non-Primary Application Packet March 2017 Page 2 of 6
 APPLICATION FOR AGENCY STAFF/NON-PRIMARY

AGENCY NAME:
APPLICANT INFORMATION:
Last Name: First: Alias: Male Female
Address (physical): City: State: Zip:
Address (mailing): City: State: Zip:
Telephone: () - Alternate Telephone: () -
Date of Birth: Place of Birth - City: State: Country:
Social Security Number: - -
Drivers License or ID Card: State: Number: Expiration Date:
Highest Grade Completed in School:
Race: American Indian or Alaskan Native Asian Black/African American
Native Hawaiian or Other Pacific Islander White/Caucasian Other (specify)
If American Indian or Alaskan Native, provide tribal name and member number:
Ethnicity: Hispanic or Latino Non-Hispanic or Latino
Are you a US Citizen? Yes No
If you are not a US Citizen, are you a Legal Resident? Yes No
If yes, provide your resident number:
Primary Language: Do you speak English fluently? Yes No Other Languages spoken:

RESIDENCE:
List the addresses where you have resided the last five (5) years. List most recent first.
Dates
Street City State Zip County
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.
Phone Mailing Address or Email Address
Name Relationship
Number (please include zip codes)
() -
() -
() -
() -
() -

1. Have you ever worked in Child Welfare, Social Services, Mental Health or for a Foster Care Agency?
Yes No If yes, list agency, dates worked/licensed:

2. Do you now or have you ever provided care for any child that is not your own? Yes No
a. If Yes, please answer the following:
Where Care was Hours per Week Care Dates Care was
Relationship to Child
Provided was Provided Provided
to
Agency Staff/Non-Primary Application Packet March 2017 Page 3 of 6
 to
to

3. Do you now or have you ever had a Child Care License? Yes No
a. If Yes, please answer the following:
i. In what state(s):
ii. Dates of licensure: to If currently licensed, attach copy of license to application.
4. Describe your general health (include any serious illnesses or disabilities).

a. Do you have any history of mental illness, drug or alcohol addiction? Yes No
If yes, please explain.
5. Are you or have you ever been prescribed any medications? Yes No If yes, table below must be
completed. A note from attending physician may be required attesting to fitness for working with children.
Medication Dosage Prescribed by Date Started & Discontinued
TO
TO
TO

EMPLOYMENT HISTORY (Direct Care Applicants only)

Please list your three (3) most recent places of employment.
Hours of Work per Dates of
Employed by Type of Work Phone Number
Week Employment
() - to
() - to
() - to

1. Give a brief statement as to your reasons for wanting to work with foster children.

2. Describe any experience you have working with children who have psychological or behavioral needs.

TRANSPORTATION (All Applicants):

Will you be responsible for providing transportation to counseling, medical appointments, visits with natural
parents, school, etc? Yes No
If no, you must attest to not drive foster children by checking this box. I agree

If yes, submit copies of your active insurance card/policy showing you as a driver.
Name of auto insurance and expiration date:

If yes, but you will only be driving an agency vehicle, please check here attesting that you will not use
your own vehicle to drive foster children. I agree

BACKGROUND INFORMATION (All Applicants):

Have you EVER been arrested, charged, and/or convicted for ANY law enforcement violation? Yes No

Agency Staff/Non-Primary Application Packet March 2017 Page 4 of 6

 a. If yes, please provide the specific details, listing ALL arrests, even if the charge(s) were later
expunged or dismissed.
b. On a separate page, please provide date of arrest, circumstances and final dispositions. Also,
provide copies that verify the final dispositions of the arrest.
Date of Arrest Nature of Arrest/Crime Final Outcome

Have you EVER had Child Protective Services, Licensing or Child Welfare Agency involvement for allegations of
child abuse and/or neglect? Yes No
a. If yes, please provide an explanation for each event on a separate page to include dates,
circumstances, and results of any allegations made.
Date Investigating Agency Allegations Outcome

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 Name Signature Date

Agency Staff/Non-Primary Application Packet March 2017 Page 5 of 6

 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 Signature Date

Agency Staff/Non-Primary Application Packet March 2017 Page 6 of 6