NH CHILD ABUSE AND NEGLECT CENTRAL REGISTRY

NAME SEARCH AUTHORIZATION RELEASE OF INFORMATION TO THIRD PARTY

I hereby request the NH Department of Health and Human Services (NH DHHS) to conduct a name search to determine if I am listed on the Department's Central Registry of founded reports of child abuse and neglect. My full legal name, other names I have used in the past, and other identifying information are listed below.

current full legal name (please print legibly):
other names (aliases) i have used, including maiden name (if applicable):
date of birth:	telephone number:
month day year
current mailing address:
I acknowledge that the results of this search can only be released to myself or a Child-Placing Agency pursuant to NH RSA 170-E, the Department of Health and Human Services pursuant to NH RSA 170-G:8-c, or another state’s Child Welfare Agency or Private Adoption Agency pursuant to NH RSA 169-C:35. I understand and authorize the results of this search to be provided to the person/agency listed below if in compliance with the aforementioned laws. Any entity listed below that is not governed under these laws will not be sent the results.
purpose of the check: (For child care see form 2503. For employment purposes, please understand that NH cannot check for other than what is listed below, individuals can check their own name)
Foster Care/Adoption	Child-Placing Agency Staff
Child Care Institutions	NH DHHS Employment (including contracted positions)
I authorize the below named agency to receive the results of my registry check. I understand that the results will not be sent to me.
Signature:	Date:
Signature: (of parent if minor)	Date:
Sign in the presence of a notary
name and address of person and agency to receive results:
number and street name	city or town	state	zip code
notary acknowledgement
State of:	In witness whereof I hereunto set my official seal.
County of:
Subscribed and sworn before me on this	day of
,	in the year	by
(name of person being checked)
Personally known	Produced Identification
Signature of notary:
My commission expires:

In order to process this request please mail this form fully completed to the Division for Children, Youth and Families, DCYF Central Registry, Thayer Building, 129 Pleasant Street Concord, NH 03301. If you enclose a self addressed stamped envelope it will expedite the mailing of the results to you.	For NH DCYF use only