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Get Informed Consent And Release Of Liability

Utah DHS-DCFS Revised May 2006 INFORMED CONSENT AND RELEASE OF LIABILITY The Utah Department of Human Services Division of Child and Family Services is authorized to investigate any past and present child abuse information which may be pertinent to your application according to UCA 62A-4a-1006 and UCA 78-30-3. 5. The release of any and all information is authorized whether it is of record or not. Please PRINT or TYPE filling in all requested information and sign in the place marked Applicant Signature. Please do not use initials to represent your first or middle name. However if your first or middle name consists of only an initial please indicate. Example J*R* initials only Doe. A complete street address is required in addition to P. O. Box numbers. All applicants are required to submit a legible copy of one of the following photo identifications Valid Drivers License State Identification Card or Passport I. D. Processing will not occur unless all requested information signatures and copy of photo I. D. are attached* Please send completed form and copy of photo identification to Utah Division of Child and Family Services 120 North 200 West Suite 225 Salt Lake City Utah 84103-1500 Attn Child Abuse Background Review Coordinator First Name Middle Name Last Name Date of Birth mm/dd/yy Social Security Number Daytime Telephone Number Home Street Address PO Box City State and Zip Code Former Names Used Including Married and Unmarried Name Dates Used from-to Other Names Used Initials Nickname Middle Name etc* Reason you are requesting a background screening Private Adoption Step Parent Adoption Employment/Volunteer work through name of agency Other please explain By signing below I certify that I have read and understand this entire form and that the information I have provided here is true accurate and complete to the best of my knowledge. I understand that providing false or incomplete information may result in delaying or possibly denying my request for background screening. It is also my understanding that under Utah Law it is a crime for an unauthorized person to require me to request a background screening as a condition of employment. I also understand that the Division of Child and Family Services may not release the results of this background screening unless I give my written consent or unless such is authorized by law. I do hereby release all persons and entities from any legal liability for furnishing such information to the State of Utah Division of Child and Family Services. Please send the results of this background screening to Name Address/City/State/Zip Code Telephone Number Applicant Signature Date. 5. The release of any and all information is authorized whether it is of record or not. Please PRINT or TYPE filling in all requested information and sign in the place marked Applicant Signature. Please do not use initials to represent your first or middle name. However if your first or middle name consists of only an initial please indicate.

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