Fillable AUTHORIZATION AND CONSENT TO RELEASE INFORMATION FROM THE (State of Idaho)

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AUTHORIZATION AND CONSENT TO RELEASE INFORMATION FROM THE (State of Idaho)

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PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE Page 1 of 2 REV 04/2019
AUTHORIZATION AND CONSENT TO RELEASE INFORMATION FROM
THE IDAHO CHILD ABUSE AND NEGLECT CENTRAL REGISTRY
INSTRUCTIONS
- This form must be completed in its entirety.
- It must be signed by the person that is being checked, or, by their parent/guardian if the subject of the search
is under the age of eighteen (18).
- The signature must be notarized.
- Include a check, money order, or appropriate invoice in the amount of $20.00 payable to: “Idaho Department
of Health and Welfare” or “IDHW”. DO NOT SEND CASH.
- Requests must
be mailed to:
IDHW – Criminal History Unit
ATTN: CWIS
P.O. Box 83720
Boise, Idaho 83720
PERSON BEING CHECKED (PRINT CLEARLY OR TYPE):
IF THE FORM IS ILLEGIBLE OR INCOMPLETE, IT WILL BE REJECTED AND RETURNED
LAST NAME:
FIRST NAME:
MAIDEN/FORMER NAME(S)/ALIASES:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
AGENCY INFORMATION:
IF THIS REQUEST IS FOR A CITY DAYCARE LICENSE, LIST THE CITY NAME AS THE LICENSING AGENCY IN THE SECTION BELOW
LICENSING AGENCY/EMPLOYER NAME:
RETURN RESULTS TO:
IF AN EMAIL ADDRESS IS PROVIDED, THAT WILL BE THE DEFAULT RETURN PROCESS
NAME:
STREET/PO BOX:
EMAIL:
CITY/STATE/ZIP: FAX NUMBER:
REASON FOR REQUEST:
SELECT THE REASON TO SEARCH THE IDAHO CHILD PROTECTION REGISTRY. IF THE REASON FOR THE REQUEST IS NOT LISTED, SELECT “OTHER”
AND SPECIFY THE LAW/ORDINANCE REQUIRING THE CHECK TO BE COMPLETED.
Foster Care/Adoption/ICPC (Adam Walsh Act 42 USC 16961 Section 152)
Child Care Employment (CCDBG)
Guardian ad Litem/Court Appointed Special Advocate
Other (must specify law/ordinance):
PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE Page 2 of 2 REV 04/2019
AUTHORIZATION AND CONSENT TO RELEASE INFORMATION FROM
THE IDAHO CHILD ABUSE AND NEGLECT CENTRAL REGISTRY
IMPORTANT:
THIS REQUEST CANNOT BE PROCESSED WITHOUT THE NOTARIZED SIGNATURE OF THE PERSON BEING CHECKED
I authorize and direct the Idaho Department of Health and Welfare Criminal History Unit to release the results of this search of the Child Abuse and Neglect
Central Registry to the agency above.
I understand that the results and information about me contained in the Child Abuse and Neglect Central Registry may prove to be unfavorable to me and that a
history of substantiated child abuse or neglect will effect my ability to work with children or vulnerable adults. I further understand that this information may
later be disclosed by the individual/organization listed above. I do hereby fully, finally and forever discharge, release, acquit, and hold harmless the Idaho
Department of Health and Welfare, its officers, agents, employees, and staff from any and all claims, liens, demands, liability, suits, judgments, or actions of
whatever kind, whether known or unknown, which I may have at any time associated with the release of information I have requested using this form. If it
appears to me that the information in the Child Abuse and Neglect Central Registry has not been updated or appears inaccurate, I will notify the Idaho
Department of Health and Welfare immediately. This authorization and consent shall be binding upon my heirs, representatives, executors, administrators,
assigns, and successors and no promise, inducement or agreement not herein expressed has been made to me. The terms of this authorization and consent are
contractual in nature and are not mere recitals. This is a continuing authorization and consent which shall remain effective until revoked by me in writing.
THE UNDERSIGNED HAVE READ THE FOREGOING AND FULLY UNDERSTAND IT.
PRINT NAME:
SIGN (PARENT/GUARDIAN IF UNDER 18):
STATE OF ______________
COUNTY OF ____________
SUBSCRIBED AND SWORN (OR AFFIRMED) BEFORE ME THIS _________ DAY OF ________________, 20_____.
NOTARY PUBLIC SIGNATURE _______________________________________
MY COMMISSION EXPIRES ON ______________________________________
SEAL
RESULTS:
TO BE COMPLETED BY IDHW STAFF ONLY
THE ABOVED NAMED INDIVIDUAL IS NOT LISTED ON THE IDAHO CHILD ABUSE AND NEGLECT
CENTRAL REGISTRY.
THE ABOVED NAMED INDIVIDUAL IS LISTED ON THE IDAHO CHILD ABUSE AND NEGLECT
CENTRAL REGISTRY.
UNABLE TO PROCESS DUE TO:
INCOMPLETE FORM
PAYMENT NOT INCLUDED
ILLEGIBLE – UNABLE TO READ INFORMATION ON FORM
OTHER:
COMPLETED BY: (IDHW STAFF ONLY)
SIGNATURE:
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AUTHORIZATION AND CONSENT TO RELEASE INFORMATION FROM THE (State of Idaho)

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Completed 21 July 2021

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