~~ VERMONT nits protection Registry Check: VT EMPLOYERS Prin or pe clearly Tistorm des net appt regulated chit care roidesin Vermont Section | Employer Requesting Registry Check Nene erp ts How would you ket reosve the ress? Check ut one. [Dy mast resus in he se scressea, stomped envelope ve eneoses wth Pus fom [Ema rsut tone pon ‘ear that this incvidal ia current employes, contractor or velunteer ofthis faclty/agencyor has ‘been givan a condonal ofr of employment understand his formations only forthe purposes ot determining whether to hire or retain the individual to provide cae, custody, treatment, wansprtation, ‘rsupervsion of chiren or wnerable aduts. ‘Rathorzed Employer Rep Brn Name) Rathoracd Employer Rep Signature) Dale ‘Section Il. Consent From Current or Prospective Employee, Contractor, or Volunteer Ful name: Gender emse Nate ress inlding setae, Gy sat, an Coe Prone number nani area endo) 08 7 Pace ot bint sm 8/9 ‘ever nemes used fg, maiien name Last 4 apts of NEI | authoie the roease of infration of any substantation agaist me found in the Vermont Chilé Protection Rest tothe above-named faciiy/agency. (Wrospacie Caren Sia, Contac, ovo Sigaare = Dale ‘Section Il. Response from the VT Child Protection Registry (Office Use Only) [CEmployees name net found in regsey tls) Empoye's name fund nresry its. Nature of ary maine Date ottinging ‘ermmisioners Designeo (Pint) Coranisloners Designee Signature) Data ‘Sand yourcompleted foto; EMAL: AI3.Chiutd.tewnefegsinGvecon.gey FAK (802) 248.9904, MAL OOF Ota Pretezen Regist, HI Nor ie 8,280 State Dre, Wertun, vermont 08671-1080 Pose end BYU Pasta! sere Doma Srey pet corer 0 airy ace Fea).