Delaware Child Protection Registry Request Form printable pdf download

DELAWARE CHILD PROTECTION REGISTRY REQUEST FORM

Fax or Mail Request to:

DSCYF, OCCL

Criminal History Unit

1825 Faulkland Road

Wilmington, DE 19805

Phone: 302-892-5800

Fax: 302-633-5191

When requesting Child Protection Registry checks:

•

Allow 15 working days for results to be processed

•

Do not use a cover sheet

•

Do not send duplicate requests

•

Form must be submitted to DSCYF within 90 days of signature date in order to be processed

PART I. APPLICANT INFORMATION (PLEASE PRINT CLEARLY)

Name:____________________________________________________________________________________________

Last

First

Middle

Other Name(s) used: ______________________________________________ DE Drivers License #_________________

Social Security # ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Date of Birth: ___-____-_____ Sex:_______ Race:_______

mm / dd / yyyy

Address:___________________________________________________________________________________________

(Street)

(City)

(State)

(Zip)

Have you ever been involved in a substantiated case of child abuse or neglect? [ ] Yes [ ] No

If Yes, explain: _____________________________________________________________________________________

________________________________________________________________________________________________________________________

I hereby authorize The Delaware Department of Services for Children, Youth and Their Families to provide the below named

agency/organization with all substantiated cases of child abuse or neglect concerning me contained in the Child Protection Registry. I

further release the Delaware Department of Services for Children, Youth and Their Families, its officers and employees from any and

all claims arising out of or in any way connected to the release or dissemination of any information concerning me.

Signature:_________________________________________________________ Date:___________________________

Parent / Guardian Signature (If applicant is under the age of 18) ______________________________________________

PART II. AGENCY/ORGANIZATION INFORMATION - (MUST BE COMPLETED IN ORDER TO PROCESS)

Please check only one:

EDUCATION

HEALTH CARE FACILITY

CHILD CARE

OTHER __________

1234

Agency Identification Number (if applicable): _________________

Office of Clinical Studies - Suite 204G

Requesting Agency Name: ________________________________________________________________

200 Academy Street, Room 204G, Newark, DE 19716

Address: _____________________________________________________________________________

Phone: ________________

Fax:

___________

Contact Person:

___________________________

(302)831- 0212

(302)831-2708

Robert Grey rgrey@udel.edu

DSCYF USE ONLY:

The individual listed above ( ___ is listed) ( ___ is NOT listed) on the Delaware Child Protection Registry

Date: ____________

DSCYF Criminal History Unit ____________________________________________________________

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Delaware Child Protection Registry Request Form

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