CHILD ABUSE NEGLECT (CA/N) CENTRAL REGISTRY CLEARANCE

CHILD ABUSE NEGLECT (CA/N) CENTRAL REGISTRY CLEARANCE

The person whose name and identifying information, printed or typed below, will provide unsupervised care and supervision of children as an Employee.
Name

First NameMiddle NameLast Name
Sex

MaleFemale
Date of Birth

MonthDayYear
Date
Race
Current Mailing Address
Alias Maiden & Prior Married Name(s)
Name & DOB of Spouse Former Spouse(s)
Name & DOB of Children / Step Children
Alabama counties where person has lived and/or worked
To be completed by person being cleared

I authorize the Alabama Department of Human Resources to release information contained in the Child Abuse / Neglect Central Registry about me to the above named person/agency/organization. I hereby waive any right to any review or hearing to which I may otherwise be entitled. I further release the Department of Human Resources, its officers, and employees from any and all claims arising out of or in any way connected to the release or dissemination of any information concerning me.
Signature

Clear
Date*

MonthDayYear
Date
Should be Empty: