The Delaware Child Protection Registry Consent Form is a crucial document that allows individuals to authorize the release of their child abuse or neglect history from the Delaware Department of Services for Children, Youth and Their Families. This form is essential for various purposes, including employment screenings and licensing requirements. Completing the form accurately ensures that the request is processed efficiently within the designated timeframe.
The Delaware Child Protective Registry Consent Form is a crucial document designed to facilitate the exchange of information regarding child abuse and neglect cases. This form serves as a means for individuals to authorize the Delaware Department of Services for Children, Youth and Their Families to disclose their records to specified requesters. Applicants must provide essential information, including their full name, Social Security number, date of birth, and address. Additionally, the form requires the applicant to disclose whether they are listed on the registry for any substantiated cases of child abuse or neglect. Importantly, the request must be submitted within 90 days of signing the form to ensure timely processing. The document also includes a section for the requester, which can either be an agency or an individual. By signing, applicants release the Department from any claims related to the information shared, emphasizing the need for transparency in child protection matters. This form not only streamlines the process for obtaining critical information but also underscores the importance of safeguarding children and ensuring that those who work with them are properly vetted.
DELAWARE CHILD PROTECTION REGISTRY CONSENT FORM
Web Portal
Instructions
Complete the below form and fax or email directly to the Division of Professional Regulation at the contact information below:
Fax: (302) 739-2711
DE Application Number: APP-__________________
Email: customerservice.dpr@delaware.gov
Request must be within 90 days of signature date in order to be processed
PART I - APPLICANT INFORMATION
Name (Last*, First*, Middle): *___________________________, *_________________________, __________________
Other Name(s) used:
None ________________________________________________________________________
Social Security #: ________ - ________ - ___________
Date of Birth (mm/dd/yyyy)*: _____ - _____ - _______
Gender*:
Male
Female
Race: ______________________________________
Ethnicity: Hispanic
Non-Hispanic
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 requester with all substantiated cases of child abuse or neglect concerning me that are active on 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 - REQUESTER INFORMATION
Check one option below and complete required information*:
1. Agency Request – Agency Name*: DIVISION OF PROFESSIONAL REGULATION
2. Individual Request - Self
*Mandatory
Revised 6/2020
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