Child Abuse History Record Request for Private Adoption

NOTE: This form must be submitted by the agency identified at the bottom of this page. The applicant may NOT SUBMIT THIS FORM DIRECTLY to the Department of Children & Families.

LIST ALL minor household members on this form. Do not include ANY adult household members or foster care children.

(Please Print Clearly – Last Name, First, Middle)

(Include city, state, and Zip Code)

Dates at Address (Include city, state, and Zip Code) By signing this form, I, as an applicant for adoption, authorize a search for reports of abuse, neglect or abandonment investigated in which my name appears and there were “verified findings” of maltreatment of a child(ren) and I am listed as the “Caregiver Responsible”. I further understand that the central abuse hotline search is only one part of the preliminary report to the court for adoption. I understand I will be given the opportunity to discuss the findings of the report(s This consent is valid solely for the requesting agency/facility listed below on this form. (Chapter 39, F.S.)

ALL ADULT (18 & UP) HOUSEHOLD MEMBERS MUST SUBMIT A SEPARATE REQUEST FORM

Facility/Agency Name: Address:

1098 N.W. BOCA RATON BLVD., BOCA RATON, FLORIDA 33432

Email: I understand it is a misdemeanor of the first degree for any agency to use or release abuse, neglect or abandonment information to others. The information is CONFIDENTIAL and may be used only for the purpose for which it was obtained.

Printed Name and Signature of Requesting Facility/Agency Representative

email: hqw.bgs.adoptions@myflfamilies.com