Form Pps 1011 - Release Of Information
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1
2PPS 1011
REV 07/13
Page 1 of 1
State of Kansas
Child Abuse and Neglect Central Registry
Department for Children and Families
Release of Information
Prevention and Protection Services
Child Abuse and Neglect Central Registry
th
915 SW Harrison 5
Fl. Room 530-East
Topeka, Kansas 66612
I, ________________________________, give permission for the release of any information concerning
(Please print complete first, middle and last name)
myself in the Child Abuse and Neglect Central Registry to:
Contact Person:
Agency Name:
Mailing address:
Phone Number
(
)
I understand that all information released will be for the exclusive and confidential use of the above
named organization/person/agency.
I give permission for the release of any information concerning myself in the Child Abuse and Neglect
Central Registry each year while I am employed or associated with the above agency.
Yes
No
** Please complete the information below by printing in ink. Please print legibly. Do not leave any space
blank. All requested information is required to process this request. Incomplete information will result in
the release not being processed and will be returned as insufficient.**
First, Middle and Last Name
:
Maiden Name:
(Female applicant only)
Married Names, Nicknames or Other Names Used:
(Use N/A if no other names used)
Date of Birth:
Race:
Social Security #
Gender:
☐
☐
Male
Female
Signature:
Date:
Current Address:
Each request must be submitted with payment prior to the request being processed. Please attach appropriate fee of $10.00 per
release of information. All releases and fees should be sent via postal mail to the attention of DCF, Child Abuse and Neglect
Central Registry, P.O. Box 2637, Topeka, KS 66601. The following state agencies are exempt from the $10.00 fee: JJA (Central
Office or Facilities), KNI, Dept. Of Education- Central Office, KDHE, State Hospitals, State Correctional Institutions, Attorney
General’s Office, Kansas School for the Blind, Kansas School for the Deaf, Child Welfare agencies in other states. Sub-
contracting agencies are not exempt and will be assessed the $10.00 fee. Mentor record checks, i.e. Big Brothers Big Sisters, are
exempt from the $10.00 fee. For a complete list of Mentor Programs, go to:
If this is a mentor record
.
check, please make sure the box below is checked.
Mentor Program: ☐ If yes, please check
For Central Registry Use Only
_____ FEE ATTACHED
(This form supersedes CFS 1011 REV 7/11)
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