Access to Records Request

Is this your first/a new request or a follow up to one already submitted?*

This is my first/new request.This is a follow-up to a previously submitted request.

Please read the following information carefully: you are requesting access to your personal information file. All Requests are assessed for eligibility (whether the individual received a service from the Society) and for the consent(s) provided. If all consents are not provided, a File Disclosure Clerk will contact you and ask that you provide all consents within a specified period. If you do not provide the requested consents within the timeline may result in your request being closed.*
Please read the following information carefully: you are a third-party requesting records of another person. Consent is required. If all consents are not provided, a File Disclosure Clerk will contact you and ask that you provide all consents within a specified period. If you do not provide the requested within the timeline may result in your request being closed.*
Please read the following information care fully: you are a third party requesting disclosure with consent of another person or court order. Written consents are required to share any information about individuals over the age of 12 years old who may be in the record or a court order is required. If the file cannot be reasonably severed, your request may be refused. If all consents or a court order is not provided, a File Disclosure Clerk will contact you and ask that you provide all consents within a specified period. If you do not provide the requested consents or court order within the timeline may result in your request being closed.*
Please read the following information carefully: you are another Children’s Aid Society or a Child Protection Authority outside of Ontario. Interprovincial Request is required. Access to records requests for any purpose other than to assess, reduce or eliminate risk of harm to a child require written consent of all individuals over the age of 12 years old who may be in the record. If all consents are not provided, a File Disclosure Clerk will contact you and ask that you provide all consents within a specified period. If you do not provide the requested consents within the timeline may result in your request being closed.*
Please read the following information carefully: you are a third party requesting a Report on a non-parent custody applicant under the CLRAs.21.2(4). Consent and the court signed Report On Record form is required. If all consents are not provided, a File Disclosure Clerk will contact you and ask that you provide all consents within a specified period. If you do not provide the requested consents within the timeline may result in your request being closed.*
Please read the following information carefully: You have already submitted a request for access to personal information or you are a third party who has already submitted a request for information on another person. *
Please read the following information carefully: you are requesting access to your personal information file. All requests are assessed for eligibility (whether the individual received a service from the Society) and for the consent(s) provided. Consents are required to share any information about other individuals over the age of 12 years old who may be in the record or third-party information. If the file cannot be reasonably severed, your request may be refused. If all consents are not provided, a File Disclosure Clerk will contact you and ask that you provide all consents within a specified period. If you do not provide the requested consents within the timeline may result in your request being closed.*
Please read the following information carefully: you are requesting access to your personal information file. All Requests are assessed for eligibility (whether the individual received a service from the Society which allows them to be eligible for an OSAP Letter) and for the consent(s) provided.*

Request Follow-up
Jotform reference number
When did you submit your original request?

MonthDayYear
Date
What information were you seeking in your original request?*
Today's date

MonthDayYear
Date
Name of individual*

First NameLast Name
Date of birth of the individual who's record you are seeking

MonthDayYear
Date
What is your relationship to the above person? *
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact phone #
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Is there any other information you want us to know?

1) Under Part X of the Child, Youth and Family Services Act, individuals have the right to access the records of their personal information related to the provision of service to them that is in the custody or control of Simcoe Muskoka Family Connexions, subject to some exceptions.

2) If you are seeking access to your records, please complete the Access to Records consent in the next page

3) Alternatively, you can call our office at 1-800-461-4236 and ask to speak with a worker who will gather all required information.

4) Once you have submitted this form, your request will be placed in a queue. Please allow 30 days before requesting an update as to the status of your file.
Acknowledgement (a)*

C - Seeking Adoption Records
Please select below:*

I am seeking access to my own adoption recordsI am seeking access to the adoption records of:
Name*

First NameLast Name
My relationship to the above person is: *
The gender of the person I am seeking records of is:*
Date of birth of the person I am seeking records:*

MonthDayYear
Date
Please note that you can contact any Service Ontario to access the Ontario Adoption Registry.

E - OSAP Letter
Please upload form here*

Cancelof

Third Party Record Check
Acknowledgement (g)*
Contact information of the person whose record you are seeking
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please provide any other information related to your request that you wish to provide:
Please attach all relevant documentation below:

(preferred file types are PDFs to ensure we are able to view documents as intended)
File Upload*

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof

Access with Consent or Court Order
Acknowledgement (g)*
Contact information of the person whose record you are seeking
Full Name (individual 1)*

First NameLast Name
Full Name (individual 2) - if applicable

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please provide any other information related to your request that you wish to provide:
Please attach all relevant documentation below:

(preferred file types are PDFs to ensure we are able to view documents as intended)
File Upload*

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof

Disclosure to Another Children’s Aid Society or Child Protection Authority outside of Ontario
Acknowledgement (g)*
Please make a selection below:*

I am currently conducting a child protection investigation with the following individual(s)I am seeking access to an Individual(s) record for another purpose
Contact information of the primary person whose record you are seeking (additional individuals can be added in the uploaded documents)
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please provide any other information related to your request that you wish to provide:
Please attach all relevant documentation below:

(preferred file types are PDFs to ensure we are able to view documents as intended)
File Upload*

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof

Report on Records
Acknowledgement (g)*
Contact information of the person(s) whose Report On Records you are seeking
Full Name (Adult 1)*

First NameLast Name
Full Name (Adult 2)

First NameLast Name
Date of Birth (Adult 1)*

MonthDayYear
Date
Date of Birth (Adult 2)

MonthDayYear
Date
Gender (Adult 1)*
Gender (Adult 2)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please provide any other information related to your request that you wish to provide:
Please attach all relevant documentation below:

(preferred file types are PDFs to ensure we are able to view documents as intended)
File Upload*

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof

Previous Places of Residence:

When completing your request, it is possible that records could be located that match both your name and date of birth but could belong to individuals other than yourself. Finding these alternate records may cause delays in our ability to provide you with timely results in order to confirm your identity. The additional information below is necessary in order to limit the possibility of locating alternative records.
Please make a selection:*

I have lived in the following places since I reached the age of 18 years or became a parent, whichever first occurredI do not have other addresses to list (I understand that this may result in delays ifalternate records are found)
Please make a selection:

I have lived in the following places since I reached the age of 18 years or became a parent, whichever first occurredI do not have other addresses to list (I understand that this may result in delays ifalternate records are found)
City: City* Province: Province* Country: *
From this date: Date* to this date: Date* .
City: City Province: Province Country:
From this date: Date to this date: Date .
City: City Province: Province Country:
From this date: Date to this date: Date .
City: City Province: Province Country:
From this date: Date to this date: Date .
City: City Province: Province Country:
From this date: Date to this date: Date .
Acknowledgement (c)*
Records will be provided in electronic/digital format (via secure email or server). If you require records in an alternate format, please indicate the requested format below (and we will try to accommodate if available)*

Electronic/Digital format is good.Please provide it in the specified format below if available
Signature*
Today's Date

MonthDayYear
Date
This consent expires on:*

Until this request is completed60 days from date of submissionPlease provide a specific date below:

Your request is ready to be submitted. Please click the submit button below to send in your request. You will get an auto response confirming your submission to the email address you provided above
Is the information provided on this request true and accurate to the best of your knowledge?*
Should be Empty:

Access to Records Request Form

Request Follow-up

Personal Request Section

A - Child Welfare Record Check

B - Letter of Involvement

C - Seeking Adoption Records

E - OSAP Letter

F - Access to Personal Records

Third Party Record Check

Contact information of the person whose record you are seeking

Please attach all relevant documentation below:

Access with Consent or Court Order

Contact information of the person whose record you are seeking

Please attach all relevant documentation below:

Disclosure to Another Children’s Aid Society or Child Protection Authority outside of Ontario

Contact information of the primary person whose record you are seeking (additional individuals can be added in the uploaded documents)

Please attach all relevant documentation below:

Report on Records

Contact information of the person(s) whose Report On Records you are seeking

Please attach all relevant documentation below: