Apply Online – Registry Check – Consent Registry Check Vermont Agency of Human Services - Adult Protective Services - 103 S. Main Street - Ladd Hall - Waterbury, VT 05671-2306 - AND - Child Abuse Registry Unit - 103 S. Main Street - Waterbury, VT 05671-2401 - FORM CThis consent form must be filled out completely and signed by the current employee, prospective employee, contractor or volunteer and kept on file at the requesting organization. The Agency of Human Services reserves the right to audit these consent forms at any time.Current or Prospective Employee, Contractor, or Volunteer InformationName* Last First Middle Initial Gender*MaleFemaleAddress* Street Address Address Line 2 City State Zip Code LAST 4 DIGITS of Social Security Number*Phone*Birth Date*Place of Birth*Other FIRST names I have used, if any. (i.e. Nicknames, Aliases)Other LAST names I have used, if any. (i.e. Maiden Names, Aliases)(Prospective) Staff, Contractor, or Volunteer Signature*Date*PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.