NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

AUTHORIZATION for RElease of INFORMATION ON HISTORY OF CHILD ABUSE AND NEGLECT IN NEW YORK STATE

Only for Use by prospective Child Care Providers

Currently Living outside of New York State or

has lived in New York State in the past five years

I,	, hereby authorize the release to the following
agency or his/her designee

(Agency)

of

(Mailing address for agency)

(Agency phone number and email address)

by the New York Statewide Central Register of Child Abuse and Maltreatment (SCR) of all information contained within the SCR regarding indicated 1 reports in which I am a subject of the report, to the extent permitted by section 422(4)(A) of the Social Services Law, in relation to my request to be approved as a prospective child care provider.

The following is information about me, my children and other persons residing in my current household, as well as my previous New York State addresses. This information is necessary to enable the SCR to conduct a thorough search of its records. I understand that the listing of these persons will not result in the release of information regarding any reports involving them in which I was not a subject of the report.

Please note that everyone who is subject to this background/history search must complete a separate form. Use additional pages as necessary. Applicants must provide their current address and any New York State address where they have resided.

______________________

1 An indicated report is a report of child abuse and maltreatment supported by at least some credible evidence at the conclusion of an investigation.

I. Prospective Child Care Provider (Applicant)

LAST NAME	FIRST NAME	MI	SEX M F	DOB (mm/dd/yyyy) / /
MAIDEN NAME/ALIAS
CURRENT STREET ADDRESS:	CITY	STATE	ZIP	FROM / TO / / / /
PREVIOUS ADDRESS	CITY	STATE	ZIP	FROM / TO / / / /
PREVIOUS ADDRESS	CITY	STATE	ZIP	FROM / TO / / / /
PREVIOUS ADDRESS	CITY	STATE	ZIP	FROM / TO / / / /
PREVIOUS ADDRESS	CITY	STATE	ZIP	FROM / TO / / / /
PREVIOUS ADDRESS	CITY	STATE	ZIP	FROM / TO / / / /

II. Applicant’s Spouse, Children and Other Household Members

LAST NAME AND MAIDEN/ALIAS	FIRST NAME	MI	SEX M F	DOB (mm/dd/yyyy) / /
LAST NAME AND MAIDEN/ALIAS	FIRST NAME	MI	SEX M F	DOB (mm/dd/yyyy) / /
LAST NAME AND MAIDEN/ALIAS	FIRST NAME	MI	SEX M F	DOB (mm/dd/yyyy) / /
LAST NAME AND MAIDEN/ALIAS	FIRST NAME	MI	SEX M F	DOB (mm/dd/yyyy) / /
LAST NAME AND MAIDEN/ALIAS	FIRST NAME	MI	SEX M F	DOB (mm/dd/yyyy) / /
LAST NAME AND MAIDEN/ALIAS	FIRST NAME	MI	SEX M F	DOB (mm/dd/yyyy) / /
LAST NAME AND MAIDEN/ALIAS	FIRST NAME	MI	SEX M F	DOB (mm/dd/yyyy) / /
LAST NAME AND MAIDEN/ALIAS	FIRST NAME	MI	SEX M F	DOB (mm/dd/yyyy) / /

X

SIGNATURE OF APPLICANT

On this	day of	, 20	, before me personally came
to me known and known as the

same person described in and who executed the within statement, and he/she duly acknowledged to me that he/she executed the same.

Notary

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

AUTHORIZATION FOR REQUEST FOR INFORMATION

ON HISTORY OF CHILD ABUSE AND NEGLECT IN NEW YORK STATE

ONLY FOR USE BY PROSPECTIVE CHILD CARE PROVIDERS

CURRENTLY LIVING OUTSIDE OF NEW YORK STATE OR

HAS LIVED IN NEW YORK STATE IN THE PAST FIVE YEARS

Any person applying to be a child care provider who has lived in of New York State in the last five years must fill out the attached Child Care and Development Block Grant Act of 2014 Authorization form. This is to determine if the applicant was the subject (i.e., perpetrator) of an indicated report of child abuse or maltreatment (SCR).

Any person who is the named subject in an indicated report of child abuse and maltreatment (a report substantiated by at least some credible evidence) has a legal right to access that record under Section 422(4)(A)(d) of the §SSL. In order to access any such records in the possession of the SCR, the applicant should complete the enclosed form. By completing the enclosed form, the applicant is agreeing to release of such records to the agency listed on the second line of the form.

Return the completed and notarized form to: DO NOT FAX THIS FORM BACK TO US

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

STATEWIDE CENTRAL REGISTER

P.O. BOX 4480

ALBANY, NEW YORK 12204-0480

Please note, there is no fee for this service.