State Of Maryland-Child Protective Services Program Consent For Release Of Information Cps Background/adam Walsh Background Clearance Request

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State of Maryland-Child Protective Services Program
CONSENT FOR RELEASE OF INFORMATION
CPS BACKGROUND/ADAM WALSH BACKGROUND CLEARANCE REQUEST
*****PLEASE COMPLETE THIS FORM ON LINE AND THEN PRINT *****
Part I: PURPOSE OF SEARCH
A. RELEASE TO SELF:
1. To determine if I have been found responsible for an “indicated” or “unsubstantiated” disposition for a child abuse or neglect
investigation.
2. To determine if I have any remaining appeal rights.
B. RELEASE TO AN AGENCY/INDIVIDUAL RELATED TO:
Adoption
School Personnel
Day Care Center
Youth Camp Personnel Administrator
Foster Care
Institutional Employee
Family Day Care
Youth Camp Worker/Volunteer
Kinship Care
CASA
Community Mgmt. Entity
Other (Specify)
International Adoption
Custody Evaluation
Group Home/Residential Treatment Facility
Agency/Individual Name
Name of Agency Representative
Agency Address
Representative’s Phone Number
-
-
x
Representative’s Email
Part II: SEARCH INFORMATION (To be completed in full by individual whose name is being searched)
APPLICANT’S LAST NAME
FIRST NAME
MIDDLE NAME (Full)
MAIDEN/BIRTH NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SEX
RACE
- -
Male
Female
OTHER NAMES USED
NUMBER
STREET NAME
UNIT TYPE/#
CITY
STATE
ZIP CODE
DAYTIME TELEPHONE NUMBER
EMAIL ADDRESS
CURRENT SPOUSE
LAST NAME
FIRST NAME
MIDDLE NAME (Full)
DATE OF BIRTH
FULL NAMES OF ALL CHILDREN (To include adult children and children not residing with you)
LAST NAME
FIRST NAME
MIDDLE NAME (Full)
DATE OF BIRTH
If more than 3 children, attach additional paper if necessary.
Have you lived in Maryland in the past?
Yes
No
Have you worked or volunteered in Maryland in the past?
Yes
No
If yes to either question, from what years:
DHR/SSA 1279A Side 1 (02/2016 edition) (All other versions are obsolete)

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