Child Maltreatment Central Registry Check

Arkansas Department of Human Services Division of Child and Family Services Request for Child Maltreatment Central Registry Check
Reason for Registry Check (please only select one)

You are a teacher, pre-service teacher, work for or are attempting to work for a school in ArkansasYou are a potential or current employee of a childcare facility or residential facility for children/youth licensed by Arkansas Department of Human Services (DHS)You are a potential foster or adoptive parent for Arkansas DHS through the Division of Children and Family Services (DCFS)You are a potential foster parent for a private organization including therapeutic foster care licensed by Arkansas DHSYou are a foster family support, volunteer, or intern for Arkansas DCFSYou are a potential relative caregiver or legal custodian for a child in Arkansas foster careYou are a caregiver for self-direction (PALCO)You are a DCFS worker submitting for a clientYou are an out of state individual, provider, school or state agencyNone of the above applies, but you would like a registry check
Applicant Name

First NameLast Name
Maiden name/other names
SSN
Race
Age
DOB

MonthDayYear
Date
Phone
Email
example@example.com
Email #2
example@example.com

Address information

Child Information

I, blanks , verify that the information above is true and complete. I authorize the Arkansas Child Maltreatment Registry to release any information their files may contain concerning me as an offender or of a true report of child maltreatment to the requesting facility as well as to the Arkansas Department of Human Services Division of Provider Services and Quality Assurance. The results from the Central Registry may include the existence of any true reports, the date the investigation was completed, and the type of true report.
Applicant's Signature

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Date

MonthDayYear
Date
STATE OF ARKANSAS, COUNTY OF blanks Acknowledges before me the blank day of Type a label , Type a label .
Notary Public
My Commission Expires:
Should be Empty:

Arkansas Department of Human Services Division of Child and Family Services Request for Child Maltreatment Central Registry Check