Dss Form 2924 – Fill Out and Use This PDF

South Carolina Department of Social Services

Child Care Regulatory Services

CENTRAL REGISTRY RELEASE OF INFORMATION

AND COMPLIANCE STATEMENT

The SC Child Care Licensing Law, Section 63-13-40 D(1) et seq., Code of Laws states that in order to be employed by or to provide caregiver services at a childcare facility licensed, registered, or approved under this sub-article, a Central Registry check must be conducted by DSS to determine any abuse or neglect perpetrated by the person upon a child. However, as stated in Section 63-13-40 D(2), Code of Laws, a person may be provisionally employed or may provisionally provide caregiver services before the Central Registry check is completed if the person executes a sworn statement on a form provided by DSS that he or she is not on the Central Registry for having perpetrated abuse or neglect upon a child. This serves as my consent to authorize the SC DSS Office of Child Care Regulatory Services to conduct a search of the Central Registry of Child Abuse and Neglect on myself. I understand that the information may prove unfavorable to me. I agree to hold any source of information, SC DSS and its staff harmless from liability associated with the release of information I have requested using this form. I understand that all information provided on this form will be released to the individual/organization listed below. This consent is effective for a search of the Central Registry for the purpose of working in any child care facility in the State. If it appears to me that the information in the Registry has not been updated or is inaccurate, I will notify SC DSS immediately.

Name of Child Care Facility:

Name of Director/Operator:

Street Address of Facility:

City:

State:

Zip Code:

County:

Facility License/Registration/Approval Number:

Check One:

NEW Staff Member

RENEWAL

Print or Type: Spelling of entire name is required; it will be delayed if initials are used.

Name:

DOB:

Sex:

Last

First

Middle

Maiden/Former Name:

Race:

SSN:

Current Address:

Previous Address:

Signature of Applicant

Date

Witnessed by the Director/Operator

Date

Submit payment and this form to the Central Office of Child Care Regulatory Services. You will receive a written response.

Results of Search of the Central Registry and SLED Sex Offender Database

(To be completed by authorized DSS employee only.)

The applicant is not listed as a perpetrator in the Central Registry of Child Abuse and Neglect.

The applicant is listed as a perpetrator in the Central Registry of Child Abuse and Neglect. According to state law, being named as a perpetrator prohibits an individual from being employed in a child care facility.

The applicant information requires research. An additional 10 days are needed to process this request.

The applicant is not listed in the SLED Sex Offender Database.

The applicant is listed in the SLED Sex Offender Database.

Central Registry/SLED Sex Offender Database Check Completed by:

Authorized DSS Employee	Date

I AFFIRM BY THIS SWORN AND SIGNED STATEMENT THAT I AM NOT LISTED IN THE CENTRAL REGISTRY AS A PERPETRATOR OF CHILD ABUSE AND NEGLECT.

THIS FORM ONLY NEEDS TO BE NOTARIZED IF THE EMPLOYEE IS BEING HIRED PROVISIONALLY AS DEFINED BY SECTION 63-13-40 D(2) AT THE TOP OF THE FORM.

Staff’s Signature:								Staff’s Title:
SWORN TO AND SUBSCRIBED BEFORE ME
This		day of			, 20		,

Notary Public for South Carolina

My Commission Expires:

DSS Form 2924 (JUN 09) Edition of DEC 08 is obsolete.