U:\DMSS\CHU\FORMS & BROCHURES\CPR FORMS\Web Portal-CPR Consent
DELAWARE CHILD PROTECTION REGISTRY CONSENT FORM
Web Portal
Request must be within 90 days of signature date in order to be processed
PART I - APPLICANT INFORMATION
Name (Last*, First*, Middle): _________________________________________________________________________
Other Name(s) used: ________________________________________________________________________________
Social Security #: ___________________________________________________________________________________
Date of Birth (mm/dd/yyyy)*: ___________________________
Gender*: ______________________________________
Race: ________________________________________
Ethnicity: (Hispanic/Non-Hispanic) ______________________
Address (Street, City, State, Zip): ______________________________________________________________________
Are you on the Delaware Child Protection Registry for any substantiated cases of child abuse/neglect? Yes No
If yes, explain: _____________________________________________________________________________________
__________________________________________________________________________________________________________
I hereby authorize The Delaware Department of Services for Children, Youth and Their Families to provide the below named requester
with all substantiated cases of child abuse or neglect concerning me that are active on the Delaware Child Protection Registry. I further
release the Delaware Department of Services for Children, Youth and Their Families, 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: _________________________________________________________________________________________
Date: __________________________________
Parent/Guardian Signature (If applicant is under the age of 18): ______________________________________________
PART II - REQUESTER INFORMATION
Check one option below and complete required information*:
1. Agency Request – Agency Name*: Wilmington University - Office of Clinical Studies
2. Individual Request - Self
* Mandatory
