"Delaware Child Protection Registry Request Form" - Delaware

This fillable "Delaware Child Protection Registry Request Form" is a document issued by the Delaware Department of Services for Children, Youth and their Families specifically for Delaware residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

ADVERTISEMENT

Download "Delaware Child Protection Registry Request Form" - Delaware

471 times
Rate
(4.4 / 5) 28 votes
DELAWARE CHILD PROTECTION REGISTRY REQUEST FORM
Fax or Mail Request to:
OCCL, Criminal History Unit
Concord Plaza, Hagley Building
3411 Silverside Road
Wilmington, DE 19810
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: ____-____-______Gender: _____ Race:_________
mm / dd / yyyy
Address: __________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Are you on the Delaware child protection registry for any substantiated cases of child abuse/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 Delaware 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
CHILD CARE
FOSTER CARE/ADOPTION
Requesting Agency Name: ____________________________________________________________________________
Address: _________________________________________________________________________________________
Phone: ___________________ Fax: _____________________
Contact Person: _______________________________
Contact E-Mail: ___________________________________________________________________________________
DSCYF USE ONLY:
The individual listed above (__ is listed) ( ___ is NOT listed) on the Delaware Child Protection Registry
.
Date: ____________ DSCYF Criminal History Unit ____________________________________________________________
C:\Website_Internet\kids\occl\pdf\cpr-request-form.doc
DELAWARE CHILD PROTECTION REGISTRY REQUEST FORM
Fax or Mail Request to:
OCCL, Criminal History Unit
Concord Plaza, Hagley Building
3411 Silverside Road
Wilmington, DE 19810
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: ____-____-______Gender: _____ Race:_________
mm / dd / yyyy
Address: __________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Are you on the Delaware child protection registry for any substantiated cases of child abuse/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 Delaware 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
CHILD CARE
FOSTER CARE/ADOPTION
Requesting Agency Name: ____________________________________________________________________________
Address: _________________________________________________________________________________________
Phone: ___________________ Fax: _____________________
Contact Person: _______________________________
Contact E-Mail: ___________________________________________________________________________________
DSCYF USE ONLY:
The individual listed above (__ is listed) ( ___ is NOT listed) on the Delaware Child Protection Registry
.
Date: ____________ DSCYF Criminal History Unit ____________________________________________________________
C:\Website_Internet\kids\occl\pdf\cpr-request-form.doc
ADVERTISEMENT