Statement of Criminal Record

The State of Michigan Department of Consumer and Industry Services Licensing Rules for Child Care Centers states that all persons who come into direct contact with children in a nursery program “shall be of responsible character and suitable to meet the needs of children”. Each center must have a mechanism to verify the character of persons providing care to our children; therefore, Dexter Co-op Preschool respectfully requests that you complete the following statements for our school records. This form will be given to the Dexter Co-op Board President for him/her ONLY to review. As will all records provided to the school, Dexter Co-op Preschool will maintain the confidentiality of this document. Please return this form in a sealed envelope.

 

I hereby certify that I have never been convicted of a crime other than a minor traffic violation. *
The above statement is:
I hereby give permission to Dexter Co-op Preschool to confirm the above statement with law enforcement of regulatory agencies. *
The above statement is:
Birth Date
Birth Date
Parent Name *
Parent Name
Child Name *
Child Name
Class *
Signature *
ACKNOWLEDGEMENT OF NEGLECT AND ABUSE POLICY
I am aware that abuse and neglect of children is against the law. I understand that the Abuse and Neglect Policy of Dexter Coop Preschool is that any and all incidents must be reported to Child Protective Services (caregivers are mandated by law to report abuse and neglect). I understand and will comply with the above statement. I HAVE READ THE ABOVE AND AGREE TO FULFILL THE RESPONSIBILITES OF MEMBERSHIP IN THE DEXTER CO-OP PRESCHOOL.
Signature *