CPS Background / Adam Walsh Background Clearance Request

State of Maryland-Child Protective Services Program

Consent For Release of Information

My Caseworker:

Part I: PURPOSE OF SEARCH

A. RELEASE TO SELF:

To determine if I have any remaining appeal rights.
To determine if I have been found responsible for an “indicated” or “unsubstantiated” disposition for a child abuse or neglect investigation.

B. RELEASE TO AN AGENCY/INDIVIDUAL RELATED TO:

AdoptionDay Care Center
Foster CareFamily Day Care
Kinship CareCommunity Mgmt. Entity
International AdoptionGroup Home/Residential Treatment Facility
School PersonnelYouth Camp Personnel Administrator
Institutional EmployeeYouth Camp Worker/Volunteer
CASACustody Evaluation
Other(specify below):

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:

Date of Birth:
Race:
Other Names Used:
Gender:	MaleFemale
Number:
Street Name:
Unit Type/#:
City:
State:
Zip Code:
Day Time 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:

Last Name:
First Name:
Middle Name (Full):
Date of Birth:

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?:	Have you worked or volunteered in Maryland in the past?:
YesNo	YesNo

If yes to either question, from what years:

Number:	Street Name:

City:	State:

Zip Code:	Date:

Number:	Street Name:

City:	State:

Zip Code:	Date:

Number:	Street Name:

City:	State:

Zip Code:	Date:

Number:	Street Name:

City:	State:

Zip Code:	Date:

Agency

Charles County Department of Social Services, 200 Kent Avenue, La Plata, MD 20646

Part III: AUTHORIZATION

Pursuant to Code of Maryland Regulations § 07.02.07, pertaining to the confidentiality of Child Protective Services investigations and reports, I hereby authorize the Maryland Department of Human Resources (DHR) to notify (agency or individual as listed in Part I) as to whether a local department of social services has identified me as responsible for “indicated” child abuse or neglect in any record maintained by the Maryland Department of Human Resources, any local department of social services, and Child Protective Services.

PART IV: CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL BEFORE A NOTARY PUBLIC

	I hereby acknowledge that I have read, understand and agree to the terms of this document:

	By checking this box, I agree to have the clearance completed:

Enter security code:

© Charles County Department of Social Services
200 Kent Avenue
La Plata, Maryland 20646
Monday – Friday 8:00 am – 4:00 pm

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