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Get DE Child Protection Registry Request Form

__ Parent / Guardian Signature (If applicant is under the age of 18) ______________________________________________ PART II. AGENCY/ORGANIZATION INFORMATION - (MUST BE COMPLETED IN ORDER TO PROCESS) Please check only one: EDUCATION HEALTH CARE FACILITY CHILD CARE OTHER __________ 1234 Agency Identification Number (if applicable): _________________ Office of Clinical Studies - Suite 204G Requesting Agency Name: ________________________________________________________________ Academy Street,.

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