ÐÏà¡±á>þÿ <>þÿÿÿ;ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿì¥Á%` ø¿×bjbj"x"x r(@@.¨ÿÿÿÿÿÿ¤*******>âââ8$>$>ndÒÒÒÒÒ>$4$’húœ5*WÒÒWW5**ÒÒJ///WX*Ò*Ò/W//“**»Òbð‡ã1þÌâ¯ «û`0³–Oˆ–»–*»@H’Úh/BT–ÁHHH55×XHHHWWWW>>>¤â>>>â>>>******ÿÿÿÿCABINET FOR FAMILIES AND CHILDREN DEPARTMENT FOR COMMUNITY-BASED SERVICES DIVISION OF PROTECTION AND PERMANENCY RECORDS MANAGEMENT 3EG 275 EAST MAIN STREET FRANKFORT, KY 40621 CENTRAL REGISTRY CHECK FOR THE FOLLOWING TYPES OF EMPLOYMENT, STATE LAW OR KENTUCKY ADMINISTRATIVE REGULATIONS REQUIRE A CHILD ABUSE/NEGLECT (CAN) CENTRAL REGISTRY CHECK AS A CONDITION OF EMPLOYMENT. PLEASE CHECK THE CATEGORY FOR WHICH THE CAN CENTRAL REGISTRY CHECK IS BEING REQUESTED: FORMCHECKBOX Day Care Employee or Volunteer (CAN Check pursuant to 922 KAR 2:090) FORMCHECKBOX Applicant for Day Care Center Licensure (CAN Check pursuant to 922 KAR 2:090) FORMCHECKBOX Child-Placing Agency Employee (CAN Check pursuant to 922 KAR 1:310) FORMCHECKBOX Child-Caring Facility Employee (CAN Check pursuant to 922 KAR 1:300) FORMCHECKBOX IMPACT-PLUS Subcontractor (CAN Check pursuant to 907 KAR 3:030) OTHER (If none of the above categories is applicable, please explain the reason for requesting a CAN central registry check, including the statutory or regulatory authority for the request): _____CASA VOLUNTEER- KRS 620.505_____________________________________________________________ PERSONAL INFORMATION REGARDING THE INDIVIDUAL SUBMITTING TO A CAN CENTRAL REGISTRY CHECK (PLEASE PRINT AND SUBMIT IDENTIFYING INFORMATION SUCH AS A COPY OF YOUR DRIVER’S LICENSE, SOCIAL SECURITY CARD, OR BIRTH CERTIFICATE): NAME: ____________________________________________________________________________________________ (First) (Middle) (Maiden) (Last) Sex: ____________ Race: ____________________ Date of Birth: _______________________________________ Social Security Number: ________________________ Date of Initial Hire: ___________________________ Present Address: Previous Address: I hereby authorize the Cabinet for Families and Children to complete a CAN central registry check and provide the results of the check to the employer or agency listed below. I also release the Cabinet for Families and Children, its officers, agents, and employees, from any liability or damages resulting from the release of this information. Signature of the Individual Submitting to the CAN Central Registry Check Date Witness Date NAME OF EMPLOYER/AGENCY:______CASA of Lexington, Inc. __________________________________ ADDRESS: 1155 Red Mile Place _______ CITY: Lexington_______________________ STATE: KY__ ZIP: 40504 PHONE: 859-246-4334 RESULTS OF CAN CENTRAL REGISTRY CHECK [ FOR OFFICIAL USE ONLY] FORMCHECKBOX No substantiated incident of child abuse or neglect found on the registry at the time of this check. 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