Form DCF-2109 "Authorization for Release of Information for Foster Care License" - Connecticut

What Is Form DCF-2109?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DCF-2109 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-2109 "Authorization for Release of Information for Foster Care License" - Connecticut

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State of Connecticut
1 of 1
Department of Children and Families
DCF-2109
05/2017 (Rev.)
AUTHORIZATION FOR RELEASE OF INFORMATION FOR
FOSTER CARE LICENSE
Parent 1
____________________________________________________________
Name: First, Middle, Last (PLEASE PRINT)
Parent 2
____________________________________________________________
Name: First, Middle, Last (PLEASE PRINT)
DCF requires the following information from or about applicants for licensure as
foster or adoptive parents:
Local, State and FBI Criminal History Records
All persons in the household
(including fingerprints)
age 16 and over
Child Protective Services Records
All adults in household
Driver’s License (if applicable)
All adults in household
Confidentiality Agreement
All adults in household
Disciplinary Agreement
All adults in household
References
Each applicant
Copy of Marriage/Divorce Documentation
Each applicant, if applicable
Financial Statement
Each applicant
Physician’s Statement
Each household member
Physical Plant Inspection
Each dwelling (if applicable)
Landlord Name and Address
Each dwelling (if applicable)
Well Water Testing
If applicable
Alternative Heat Source Inspection
If applicable
Weapons/Safeguards
If applicable
In addition, an applicant must:
 attend all sessions of the pre-licensing training;
 complete an application form and participate in an assessment (Home
Study); and
 participate in a minimum of three interviews with a DCF Social Worker, which will
include face-to-face contact with every household member.
I/We agree to all the Department of Children and Families to have access to my home and
the documentation necessary for assessment of my/our application for a foster care license.
(Without consent, DCF cannot proceed with your application.)
SIGNATURES
Adult
Adult
Adult
State of Connecticut
1 of 1
Department of Children and Families
DCF-2109
05/2017 (Rev.)
AUTHORIZATION FOR RELEASE OF INFORMATION FOR
FOSTER CARE LICENSE
Parent 1
____________________________________________________________
Name: First, Middle, Last (PLEASE PRINT)
Parent 2
____________________________________________________________
Name: First, Middle, Last (PLEASE PRINT)
DCF requires the following information from or about applicants for licensure as
foster or adoptive parents:
Local, State and FBI Criminal History Records
All persons in the household
(including fingerprints)
age 16 and over
Child Protective Services Records
All adults in household
Driver’s License (if applicable)
All adults in household
Confidentiality Agreement
All adults in household
Disciplinary Agreement
All adults in household
References
Each applicant
Copy of Marriage/Divorce Documentation
Each applicant, if applicable
Financial Statement
Each applicant
Physician’s Statement
Each household member
Physical Plant Inspection
Each dwelling (if applicable)
Landlord Name and Address
Each dwelling (if applicable)
Well Water Testing
If applicable
Alternative Heat Source Inspection
If applicable
Weapons/Safeguards
If applicable
In addition, an applicant must:
 attend all sessions of the pre-licensing training;
 complete an application form and participate in an assessment (Home
Study); and
 participate in a minimum of three interviews with a DCF Social Worker, which will
include face-to-face contact with every household member.
I/We agree to all the Department of Children and Families to have access to my home and
the documentation necessary for assessment of my/our application for a foster care license.
(Without consent, DCF cannot proceed with your application.)
SIGNATURES
Adult
Adult
Adult