Authorization For Release Of Information For Registered Organizations Page 2
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1
2Please release the following information to the Organization listed above: (Check all that apply): .
Nebraska Child Abuse and Neglect Central Registry (CAN Registry)
Nebraska Adult Protective Services Registry (APS Registry)
1. Whether or not I am listed on the CAN Registry, and the following
1. Whether or not I am listed on the APS Registry, and the following
information regarding any listing(s) which relate or pertain
information regarding any listing(s) which relate or pertain
to me:
to me:
a. Date of the alleged child abuse or neglect; and
a. Date of the alleged adult abuse or neglect; and
b. The classification of the case pursuant to Neb. Rev. Stat. 28-720.
b. The classification of the case pursuant to Neb. Rev. Stat. 28-376.
(i.e., Agency Substantiated or Court Substantiated).
(i.e., Agency Substantiated or Court Substantiated).
This authorization is valid for a period of 6 months from the date of signature.
__________________________________________________________________________________________
___________________________
Signature of Applicant
Date
(NOTE: If Applicant is less than 19 years of age the signature of Applicant's Legal Guardian is also required below)
Section A - Verification of Identity of Applicant: Section A or B must be completed.
STATE OF_________________________________________)
) ss.
COUNTY OF_______________________________________)
The foregoing instrument was acknowledged before me this_________________day of _________________________________, 20___________ by:
_______________________________________________________________________________________________________________________
(Printed Name of Applicant) .
____________________________________________________________________
*Affix Official Notary seal here*
Notary Public
Section B - Verification of Identity of Applicant: Section A or B must be completed.
The undersigned Organization employee hereby certifies that he or she has verified the identify of the Applicant by examining the Applicant's
identification documents.
__________________________________________________________________________________________
___________________________
Signature of Organization Employee
Date
__________________________________________________________________________________________
Printed Name of Organization Employee
_____________________________________________________________________________________________ ___________________________
Signature of Applicant's Legal Guardian
Date
(NOTE: This signature is necessary only if Applicant is less than 19 years of age).
Verification of Identity of Applicant's Legal Guardian (If applicable)
STATE OF_________________________________________)
) ss.
COUNTY OF_______________________________________)
The foregoing instrument was acknowledged before me this_________________day of _________________________________, 20___________ by:
________________________________________________________________________________________________________________________
(Printed name of Applicant's Legal Guardian) .
______________________________________________________________________
*Affix Official Notary seal here*
Notary Public
CFS-5 Page 2
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