Authorization for Release of Confidential Information Contained Within the Arkansas Child Maltreatment Central Registry	EHIRE-164 04/07/2021
I hereby request that the Arkansas Child Maltreatment Central Registry release any information their files may contain including the undersigned individual as an alleged perpetrator of suspected child abuse/neglect. This information should be addressed to: Human Resources, Arkansas Cooperative Extension Service, 2301 S. University Ave., Little Rock, AR 72204. I understand that the name of any confidential informants, or other information which does not pertain to the individual as alleged perpetrator, will not be released. Please scan and send completed and notarized forms to centralregistry@uada.edu or mail to the address above.
PLEASE TYPE OR PRINT
Last Name	First Name	Middle Name
Maiden Name, Aliases, and any other name(s) you have used
Date of Birth	Race	Female	Male
SSN#	County of Residence:
Please select whether you are a volunteer or a UA Division of Agriculture employee. List the appropriate county or work location.
4-H Volunteer in	County	OR	UADA Employee	Work location
Addresses for last 10 years (include Zip code)	From	To Present
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4.
5.
Names and Birth Dates (DOB) of Children
Last Name	First Name	DOB
Last Name	First Name	DOB
Last Name	First Name	DOB
Last Name	First Name	DOB
Last Name	First Name	DOB
Signature
County Of	State of Arkansas
Acknowledged before me this	Day of	20
Notary Public
My Commission Expires
The University of Arkansas System Division of Agriculture offers all its Extension and Research programs and services to all eligible persons without regard to race, color, sex, gender identity, sexual orientation, national origin, religion, age, disability, marital or veteran status, genetic information, or any other legally protected status, and is an Affirmative Action/Equal Opportunity Employer.