2024 Band Camp Central Registry Document

2024 Band Camp Central Registry Document
Student Name*

First NameLast Name
INSTRUCTIONS- Complete ONLY if you will be attending Band Camp:

· An enlarged and clear copy of individual’s photo identification must be attached.

· For Michigan employers, individuals and volunteer agencies, submit this request to the local County Department of Human Services. To obtain the address and fax number of your local county DHS, access www.michigan.gov/dhs->Inside DHS.

· For individuals seeking clearance on themselves, the results will be sent to the address on the picture identification provided.

· Outstate Children’s Protective Services workers, law-enforcement, and court officials fax request to 517-241-7047 (Outstate only) on agency letterhead with cover sheet.

All fields must be completed for processing.
Parent/Guardian Full Name*

First NameMiddle NameLast Name
Also Known As Name (AKA) or Maiden Name
Social Security Number*
Birthday*

MonthDayYear
Address*

Street Address

Street Address Line 2 (if applicable)

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Today's Date*

MonthDayYear
Date
Signature*

Clear
Photo of state issued ID, this is your Drivers License or State ID (Please make sure address above matches your ID address)*
Back of ID (ONLY Needed if change of address is on back)
Select Individual
Name Of Organization
Name Of Requester
Email
example@example.com
Address
City
State
Zip
Fax Number
Phone Number
Should be Empty: