Voluntary Foster Care Registry Registration Form For purposes of completing this application, the term “immediate birth family member” applies only to a birth mother, birth father, biological child or biological sibling. Additionally, the term “registrant” means an individual, 18 years or older, who was, or currently is, in the legal custody of Child and Family Services Agency (“CFSA”) or an immediate birth family member of that person. The Voluntary Foster Care Registry cannot be used to locate grandparents, guardians or other extended family members.
You are responsible for contacting CFSA and updating your contact information should you relocate or your contact information changes. Failure to update your contact information will make it difficult for CFSA to successfully match you with your immediate birth family members in the registry.
PLEASE DELIVER THE COMPLETED ORIGINAL FORM ALONG WITH A COPY OF YOUR DRIVER’S LICENSE OR SOME FORM OF GOVERNMENT ISSUED IDENTIFICATION TO:
Child and Family Services Agency
200 I. Street, S.E.
Washington, DC 20003
Attn: Voluntary Foster Care Registry
Part I: Registrant Information [Please PRINT or TYPE]
Initial Registration Modify Existing Registration
Registrant Classification (please check only one): Are you the Birth Parent Birth Sibling Foster Youth
NAME:___________________________________________________________________ Gender: M F
Last First Middle D.O.B. __________ Social Security No. ______--_____--_______ Race: ___________________________
List all names (Last, First, Middle) ever used (maiden, married, pre-adoptive, alias, etc.):
Address (include apt. number if applicable) City State Length of Residency ________________________________________________________________________________________
Telephone Numbers: Home Cell Work Email Were you adopted? Yes or No
Are you trying to locate a birth child/sibling who was adopted? Yes or No
If you were in foster care, in what year did your foster care case close? _______
PART II: Immediate Birth Family Information. In the table below, please list the names (and relationship to you) of the immediate birth family members (as defined above) with whom you would like to reconnect through the Voluntary Foster Care Registry. Please mark the Consent box (and initial next to it) for each family member for whom you give consent to receive your contact information in the event of a match. If there is any further contact information, physical description, or other details about these family members that may help us confirm a match, please provide it on additional sheets.
Name (Last, First), Gender, & Relationship to Registrant
PART III: Registrant Consent to Release of Information In the event of a registrant match, CFSA is required by law to obtain independent verification of a familial relationship by contacting one or more of the following entities:
D.C. Superior Court
Vital Records Division of the D.C. Department of Health
D.C. Collaborative Agencies and/or local departments of social services
By signing below, I authorize the above entities to disclose information from my file (including HIPAA protected information) to CFSA for the sole purpose of verifying my familial relationships with immediate birth family members, as required by the District’s Voluntary Foster Care Registry. I understand that this information cannot be re-disclosed by CFSA without my written authorization.
By signing below, I also give express consent to CFSA to release my contact information to the immediate birth family members for whom I indicated consent in Section II of this registration form. I understand that these family members must also be registrants in the Voluntary Foster Care Registry in order to receive this information.
PART IV: District of Columbia Notarization. Please have a District of Columbia Notary Public fill out this section. CFSA can provide Notary services if you fill out the application in person at the Voluntary Foster Care Registry Above.
Subscribed and affirmed or sworn to me, in my presence,
on this __________day of ______________________, 20____.
Signature of Notary Public
Notary Public, District of Columbia
My commission expires on ___/___/____.
YOU HAVE THE RIGHT TO WITHDRAW FROM THE REGISTRY AT ANY TIME.
In order to withdraw from the registry, please submit a letter to the Child and Family Services Agency that includes your name and a request to be removed from the Registry. The letter must be signed, notarized, and sent to the address above.
If you have questions, please call the CFSA Voluntary Foster Care Registry at (202) 442-6188 or email email@example.com Page of