Instructions for completing the statewide Central Register of Child Abuse and Maltreatment
(MAC users: Please be aware you will need to download Adobe for the MAC prior to filling out this form.
http://www.adobe.com/support/downloads/product.jsp?platform=macintosh&product=10 You will be able to open it with
“Preview,” but we will not be able to see your entries.)
Please return this form by emailing it to cbergman@hillside.com within 2-business days. Be aware that this
form may take up to an hour to complete.
The first page following the instructions is the Notice & Release of Social Service Law 424-A. Please read this
notice and release and sign. You may sign electronically by using an electronic signature that you have created
or simply by typing your name on the top two lines of the notice and release form. Please type the date that you
are completing the form on the third line.
The second page following the instructions is the live form. This form will need dates of all your permanent addresses for
the last 28 years or birth - whichever comes first. You only need to use your permanent address – places you received
official mail (pay stubs or tax forms). If you had a temporary residence (example: college dorm/house), but used a
different address for your official mailing address, you do not need to put the temporary address down. The state has very
specific requirements so please ensure every section is completed.
Top of the form
Start with your information in the top box (last name, first name, sex (M/F) and date of birth).
Second Box is if you have a maiden/alias name. If No, please write N/A in the box.
The next set of boxes is for all of the people who live in your CURRENT permanent address.
Start with what relationship these people have to you, then list last name, first name, sex (M/F) and date of birth.
Bottom of the form
Start with your current permanent address FIRST and work backwards. Please make the dates a seamless...