Authorization For Release Of Information For Registered Organizations
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1
2Division of Children and Family Services (CFS)
*CFS5*
Nebraska Child Abuse and Neglect Central Registry (CAN Registry)/
Nebraska Adult Protective Services Central Registry (APS Registry)
Authorization for Release of Information for Registered Organizations
All designated fields must be completed or the request will be returned and not processed. Please type or print legibly. This form is for use
only by organizations who have registered with CFS to obtain CAN Registry and/or APS Registry information. For information on how
to register your organization go to: .
ORGANIZATION INFORMATION
Registered Organization ID Number
Registered Organization Name
2231
Nebraska 4-H Youth Development
APPLICANT INFORMATION
First
Middle
Last Name
Date of Birth
Age
Social Security Number
Current Address
City
State
Zip Code
Applicant's E-Mail Address (Please leave the E-Mail field blank if you prefer to receive correspondence by U.S. Mail).
Other names, such as a maiden name, former married name, or nickname, used in the past 20 years:
Names and birthdates of your children and children who lived with you:
All previous addresses at which you have resided in the past 20 years (minimum City & State):
Volunteer County ______________________
*2231*
CFS-5 Rev. 12/15 (65655)
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Parent category: Legal