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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