DHS-1929 (Rev. 2-18) Previous edition obsolete. 1
CENTRAL REGISTRY CLEARANCE REQUEST
Attach a Separate Page
Michigan Department of Health and Human Services
SECTION 1 INFORMATION ON PERSON BEING CLEARED
Name, (First, Middle, Last) Signature Required for Individual Being Cleared Date
Also Known as Name (AKA) Social Security Number Date of Birth
Address City State Zip Code
Phone Number Email
I am completing this for myself.
I would like to pick up my results
in
County (For Michigan Residents Only).
SECTION 2 REQUESTER INFORMATION
Please Check Appropriate Box
Employer
Volunteer Agency
Adoption/Foster Care Home Screening
Court/Law-Enforcement/Department of Corrections/Prosecuting
Attorney
Other
School
Name of Agency or Organization
South Olive Christian School
Name of Requester
Administrative Assistant
Address City State Zip Code
6230 120
th
Ave Holland MI 49424
Email Fax Phone Number
[email protected] 616-875-2287 616-875-8224
Employers/Volunteer Agencies will ONLY receive responses of NO central registry if the person being cleared has approved this request with their signature. Employers/volunteer agencies will NOT receive
notification if the name submitted has any central registry hits per CPL 722.627. For questions about completing this form, please contact the local Michigan Department of Health and Human Services, see
attached contact list.
This clearance does not identify individuals who may have child abuse/neglect history in other states, territories or tribal trust land.
The confidentiality of central registry information is protected by Sections 7 through 7j of the Michigan Child Protection Law (MCL 722.627-722.627j). Anyone who violates this protection is guilty of a
misdemeanor and is civilly liable for damages.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status,
genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
Or have the school office do this for you.
Insert a picture of your license here