Volunteer Forms Home » How To Help » Become a CASA Volunteer » Volunteer Forms CASA Volunteer Form 1Central Registry Check2Criminal Record Request3Adult Protection Registry4Submit DPP-156 Central Registry CheckChild Abuse or Neglect Check (CA/N)(Required)For the following types of employment or volunteerism, state law or Kentucky administrative regulation authorizes a child abuse/neglect (CA/N) Check as a condition of employment or volunteerism (www.lrc.ky.gov). Please check the category listed below that applies to you for which the child abuse or neglect check is being requested: Child-Placing Agency (Foster/Adoption/Independent Living) Employee or Volunteer (Required by 922 KAR 1:310) Residential Child-Caring Facility Employee or Volunteer (Required by 922 KAR 1:300) (Institution/Group Home/Emergency) Public School Employee, Student Teacher, Contractor, or School-Based Decision-Making Council Member (Required by KRS 160.380) Private, Parochial, or Church School Employee or Student-Teacher (Permitted by KRS 160.151) Youth Camp Employee, Contractor, or Volunteer (Required by KRS 194A.380-194A.383) Power of Attorney Regarding the Care and Custody of a Child (Required by KRS 403.352) Supports for Community Living (SCL) Employee (Required by 907 KAR 12:010) Michelle P. Waiver Michelle P. Waiver (Required by 907 KAR 1:835) Home and Community Based (HCB) Waiver (Required by 907 KAR 1:160 and 7:010) Acquired Brain Injury Waiver Services (Required by 907 KAR 3:090) Children’s Advocacy Center (Required by 922 KAR 1:580) Court Appointed Special Advocate (CASA) (Required by KRS 620.515) Personal Care Attendant (Required by 910 KAR 1:090) Other Other(Required)(If none of the above categories is applicable, please explain the reason for requesting a child abuse or neglect check, including the statutory or regulatory authority for the request):Personal information regarding the individual submitting to a child abuse or neglect check (Please print and submit identifying information such as a copy of your driver’s license, social security card, or birth certificate):Name(Required) First Middle Last Maiden/Nickname/OtherGender(Required) Male Female Race(Required)Date of Birth(Required) Month Day Year Social Security/Individual Taxpayer Identification #(Required)Phone(Required)Email(Required) Date of Initial Hire(Required) Month Day Year Present AddressDate(Required) Month Day Year Address(Required) Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address 1Date Month Day Year Previous Address Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address 2Date Month Day Year Previous Address 2 Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address 3Date Month Day Year Previous Address 3 Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address 4Date Month Day Year Previous Address 4 Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address 5Date Month Day Year Previous Address 5 Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Work or School LocationsList any states outside of Kentucky where you have worked or attended school in the last five (5) years, including dates, beginning with the most recent. Background checks must cover all in which one has worked or attended school during the previous five years. Use a separate piece of paper if necessary.Previous Work or School Locations 1Date Month Day Year Previous Work or School Locations 1 Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Work or School Locations 2Date Month Day Year Previous Work or School Locations 2 Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Work or School Locations 3Date Month Day Year Previous Work or School Locations 3 Street Address Apt/Unit # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Drivers LicensePlease upload the front face of your driver's license(Required) Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, Max. file size: 12 MB. CENTRAL REGISTRY CHECK A credit or debit card payment in the amount of ten dollars ($10.00) must accompany your request to process a Child Abuse or Neglect Check. The Child Abuse or Neglect Check will NOT be processed without payment. I hereby authorize the Cabinet for Health and Family Services to complete a Child Abuse or Neglect check and to submit the results of the check to me and, on my behalf, to the employer or agency listed below. I also release the Cabinet for Health and Family Services, its officers, agents, and employees, from any liability or damages resulting from the release of this information. All the information provided is complete and true to the best of my knowledge. I understand if I give false information or do not report all of the information needed, I may be subject to prosecution for fraud.Signature of the Individual Submitting to the Child Abuse or Neglect Check(Required)Date(Required) Month Day Year PDF Preview AOC-RU-004 Criminal Record RequestThe process to obtain the information contained in CourtNet is as follows: Individuals Requesting a record on yourself requires a $25.00 fee (check or money order). If you do not receive a response in 30 days contact us at the number listed above. Nonprofit/Commercial/Others Requesting a record on individuals requires a $25.00 fee (check or money order). Fees are paid to the order of the KENTUCKY STATE TREASURER by check or money order ONLY. FAILURE TO COMPLY WITH THESE PROCEDURES WILL RESULT IN THE REQUEST BEING RETURNED UNPROCESSED. If you suspect information contained on the record is incorrect, or have any questions, please contact the Records Unit at (502) 573-1682 or (800) 928-6381.DLN(Required)Street Address/P.O. Box(Required)I understand the information supplied by me must be truthful and falsification with an intent to mislead may result in my prosecution under KRS 523.100. I have provided the basic information necessary to qualify for record processing and exemption of fees - if applicable.Please denote which purpose applies to this request: Employment(Required) Criminal Investigation Screening Housing Applicants Volunteer/Care over Juvenile Licensing Other Please Explain(Required)Signature(Required)Date(Required) Month Day Year PDF Preview Adult Protection Registry ReleaseThe Cabinet for Health and Family Services administers the Adult Caregiver Misconduct Registry, enacted by the 2014 Kentucky Legislative session. In accordance with KRS 209.032, information on file in the Adult Caregiver Misconduct Registry includes the listing of a person's name on the Registry based on a cabinet finding of substantiated adult abuse, neglect, or exploitation which has been “validated” meaning that the listing has been finalized after an appeal, or that no appeal was requested within the time permitted. It is not a criminal finding. The information in the registry is available to entities that provide care services to vulnerable adults to query as to whether a prospective or current employee contractor or volunteer has been subject to a validated substantiated finding. This Adult Caregiver Misconduct Registry is also available for a self-query to determine whether a validated substantiated finding of adult abuse, neglect, or exploitation has been entered against him or her. Fraudulent use of this system for any other reason is restricted and controlled by the Criminal Penal Code. I attest that I am a representative of a Vulnerable Adult Service Provider as defined in KRS 209.032 or an individual making a self-query as defined in KRS 209.032 authorized to submit a query under KRS 209.032. I understand that accessing or releasing confidential information and/or records or causing confidential information and/or records to be accessed or released to persons or entities not authorized under KRS 209.140 is a violation of this agreement and the law which may result in criminal or civil liability. I attest that I am a representative of a Vulnerable Adult Service Provider as defined in KRS 209.032 or an individual making a self-query as defined in KRS 209.032 authorized to submit a query under KRS 209.032. I understand that accessing or releasing confidential information and/or records or causing confidential information and/or records to be accessed or released to persons or entities not authorized under KRS 209.140 is a violation of this agreement and the law which may result in criminal or civil liability.Applicant(Required)Date(Required) Month Day Year Witness(Required)Date(Required) Month Day Year PDF Preview Submit ApplicationConsent Agreement(Required)By submitting this form: 1. Central Registry Check Authorization: I acknowledge and understand the requirements set by the Commonwealth of Kentucky for a child abuse/neglect (CA/N) check based on my category of employment or volunteerism. I hereby authorize the Cabinet for Health and Family Services to complete a Child Abuse or Neglect check on my behalf and, if necessary, share the results with the specified employer or agency. 2. CourtNet Record Request: I understand the process and fees associated with obtaining information from CourtNet. I attest that all information provided by me is truthful. I am aware that any falsification with an intent to mislead may result in prosecution under KRS 523.100. 3. Adult Protection Registry Release: I understand the purpose and implications of the Adult Caregiver Misconduct Registry. I authorize CASA of OHIO VALLEY to complete a self-query using the web-based registry on my behalf and release them from any liability or damages resulting from conducting the self-query. By clicking "Submit", I confirm that I have read, understood, and agree to the terms outlined above. I agreeUnique IDUnique ID Alt
