Child Abuse Register Consent To Disclosure Of Information Form B2 - Nova Scotia Department Of Community Service
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1Child Abuse Register
Consent to Disclosure of Information Form B2
Department of Community Services
We are authorized to search the Nova Scotia Child Abuse Register only if you have contact with children under the age of 16.
1 Give your details
(please print)
Last name: ______________________________________________
First name: __________________________________________
Middle names: ________________________________________
Last name at birth, if different from above: ___________________
All other last names during your lifetime: _____________________________________________________________________________
Commonly used names, nicknames, aliases: _________________________________________________________________________
Date of birth (dd/mm/yyyy): _____________________________________ Gender:
Male
Female
Health card number: __________________________________________ Drivers license master number: _______________________
Current mailing address: _________________________________________________________________________________________
___________________________________________________________ Postal Code: ______________________________________
Phone numbers: Home _______________________________________ Cell _____________________________________________
How long have you been a resident of Nova Scotia? ______________ years
_____________ months
Name of agency, organization or employer requesting this search: ________________________________________________________
2 Give reasons for the search
Describe the nature and extent of your contact with children. Note that the register contains names of persons convicted of an offense
against a child, and persons found by a Nova Scotia family court to have abused a child. Search results are for Nova Scotia only.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
3 Attach photocopy to prove your identity
Proof of identification must be included. Applications cannot be processed without a valid:
Driver’s license or
Health card
If you do not have proof of identification please contact us at the number listed at the bottom of this form.
4 Sign the consent and certification
I give my consent for the Department of Community Services to disclose to the agency, organization, or employer requesting this
search, that my name is not entered in the Nova Scotia Child Abuse Register.
I certify that the information given on this
form is correct.
Signature: __________________________________________________ Date: ____________________________________________
For staff use only
5 Return the form
As of this date, _______________________________________ the name of
Return this form to the agency, organization or employer
the above HAS NOT been entered in the Child Abuse Register.
requesting the search. We will send confirmation that your
name does not appear on the register to them.
Consent withdrawn by applicant
Authorized signature: ________________________________________________
Certified by the Department
of Community Services
Questions? Call 902-424-6798
Child Abuse Register
(stamp)
FCS-603 30102008 V.03
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