Note: Prior Contact Checks will be required at other stages in the adoption process. The Agency will advise you when these are required.

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MINISTRY OF CHILDREN AND FAMILY DEVELOPMENT (MCFD) PRIOR CONTACT CHECK (PCC) - 4 forms: Prior Contact Check Request Consent for Prior Contact Check Consent to Share Information Form C Results of

1 MINISTRY OF CHILDREN AND FAMILY DEVELOPMENT (MCFD) PRIOR CONTACT CHECK (PCC) - 4 forms: Prior Contact Check Request Consent for Prior Contact Check Consent to Share Information Form C Results of Prior Contact Check Applicants must complete the first form: Prior Contact Check Request. Each person in the household over 19 years of age must complete the following forms individually: Consent for Prior Contact Check and Consent to Share Information Form C. Applicants need to enter all names on the third form: Results of Prior Contact Check. Please take ALL 4 forms with you to your local MCFD - Adoption & Guardianship office. Acceptable identification: One piece must be issued by a government agency with a photograph (i.e. Driver s License, Passport, BCID) and the other should be your Care Card. They will then mail/fax the RESULTS form back to FSGV Adoption Agency. Please contact your local Ministry office in advance to arrange to have the Prior Contact Check completed. Let them know that you have been directed by FSGV Adoption Agency to bring the forms in for completion. There are no fees. If applicable, either spouse can take the other s two pieces of identification (one picture I.D. and Care Card), to complete the PCC on their behalf. Other persons over the age of 19 must appear in person with their two pieces of identification (one picture I.D. and Care Card). Contact Information for Ministry adoption offices: Vancouver, Richmond, North Shore & West Vancouver areas: 3455 Victoria Drive, Vancouver (9am 12pm & 1pm - 4pm) Surrey, Tsawwassen, Ladner, Delta, White Rock, Aldergrove, Langley & Fort Langley: Whalley Boulevard, Surrey (corner of Whalley Blvd and 104A Ave.,) (8:30am 4:30pm) **PLEASE NOTE: Please call for an appointment Tel: Burnaby, New Westminster, Coquitlam, Port Moody, Tri-Cities, Maple Ridge, Pitt Meadows: Suite # Halifax Street, Burnaby, BC V5C 5R4 Tel: Abbotsford & Mission: 3 rd Floor, 2828 Cruickshank Street, Abbotsford Chilliwack & Fraser Cascade: 8978 School Street, Chilliwack Victoria & South Island: 1 st Floor, 1195 Esquimalt Road, Victoria For other areas of the province: check the blue pages of your telephone directory or call Inquiry BC in the Lower Mainland, or for the rest of the province. Ask for the Ministry of Children and Family Development office, which provides adoption services in your area. Note: Prior Contact Checks will be required at other stages in the adoption process. The Agency will advise you when these are required. A05A June/14 Page 1 of 1

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3 ª " y z { z } ~ ƒ ~ ~ z z } z ˆ ~ y } ƒ ~ } ~ z z ˆ ˆ z y z y ~ Š ~ ƒ ˆ Œ z } z ˆ ƒ ~ y z { { ~ } z ~ ƒ ˆ } z y z Ž Ž ˆ ~ y z š œ œ œ ž Ž Ÿ ˆ z z } z } y z ~ z z ˆ ƒ ~ ~ Š Œ z } Œ z ~ ˆ } ~ } z } { z y z ˆ ~ y z š œ œ Ž Ÿ ƒ Š ~ y z Š z } ~ } Œ ~ y z!! " # $ " % & & & & ' ( ( ' ) ) * % # $ * # +, " # -. / : 2 ; 5 : : < = < > 4 <? : 2 : < ; : : < 2 A 5 : : 6 B 4 <? C : D D E F : = < > 7 8 ; 9 = D? 5 : < G H 4 A = I : = 7 5 ; 7 < 6 4 ; 6 ; 9 : ; J 6 7 F : ; 7 <? A ; 6 :? 7 : F B 4? : D : > 4 6 : K = 5 : ; A <? : : L M N O P Q R S T N O U S V P L W T T X V N Y U Z [ \ ] N ^ [ _ ^ Y : _ P W ` Y N W V _ ^ Y a = 7 5 ; 7 < 6 4 ; 6 ; 9 : ; J = : b = : C D D 5 : ; 7 5? 2 4 F 7 A : ; 7 D D : ; 6 :? A <? : : R S T N O U S V P L M N O P Z [ \ ] N ^ [ _ ^ Y G 6 9 : L M N O P Q R S T N O U S V P L W T T X V N Y U Z [ \ ] N ^ [ _ ^ Y 4 <? c : _ P W ` Y N W V _ ^ Y : D : ; < = ; d H 8 = < = 7 < = A <? A > : 3 5 = 7 5 ; 7 < 6 4 ; 6 ; 9 : ; J 4 <? = 6 = 2 5 : D : b 4 < : 2 2 = 4 6 :? C 7 5 J : 5 6 7? = 2 ; A : = < = 7 < d e 9 : = < = 7 < C = D D < 7 6 F :? = 2 ; D 7 2 :? 4 < = I 4 6 = 7 < G > : < ; B 7 A : f = < = B 7 8 g 9 = D? 5 : < 4 <? h = D B K : b : D 7 : < K : D : > 4 6 :? 1 F 7 5 = > = < 4 D 1 > : < ; B C = A B J < 7 C D :? > : 4 <? ; 7 < 2 : < 6 d e 9 : 8 7 g 7 < 2 : < K = 2 ; D 7 2 A 5 : 7 8 H < = 7 : < 6 = 2 b 4 D =? : 5 = 7? < : B : " # * * - " 6 9 :? 4 6 : = > < 4 6 A 5 : d! " q & & & & ' ( ( ' ) ) r s / t p o #! - "! # - u # v #! " " # " " - # w " # * % # $ x $ ³ µ µ ¹ º» ¼ µ ½ ¾ ³ ½ ³ ½ À Á Â Ã ¼ Ä Å ¹ º Ä ¹ Æ Ç È Ä ¹ À É Ç Ã ¼ Ã Ê Â ¹ Æ Â º ¹ Ë ³ Ì Í À É º Î Â Ã º ¼ À Ä µ ¼ Á + Ï ±, ««+ Ï ±, «± ²

4 CONSENT TO DISCLOSURE OF INFORMATION CONSENT TO SHARE FORM INFORMATION C FORM C I, consent to the disclosure of information about: me a child who is in my legal care and is under 12 years of age I consent to the disclosure of: all information all information with exception of the following: the following specific information only: Prior Contact Check Name(s): Address(es): Phone/Fax: Family Services of Greater Vancouver Adoption Agency for the following purpose: East Broadway, Vancouver, BC V6N 1W1 (P) (F) Relative to my application to adopt a child Date: Signature of person giving consent: Name of the Director s delegate: Shelley Brownell, RSW, BSW, Acting Program Manager - Administrator This consent is valid for one year unless revoked in writing by the person giving consent. PCC- Consent to Share Information Form C A05E SEP/10 Page 1 of 1

5 CONSENT TO DISCLOSURE OF INFORMATION CONSENT TO SHARE FORM INFORMATION C FORM C I, consent to the disclosure of information about: me a child who is in my legal care and is under 12 years of age I consent to the disclosure of: all information all information with exception of the following: the following specific information only: Prior Contact Check Name(s): Address(es): Phone/Fax: Family Services of Greater Vancouver Adoption Agency for the following purpose: East Broadway, Vancouver, BC V6N 1W1 (P) (F) Relative to my application to adopt a child Date: Signature of person giving consent: Name of the Director s delegate: Shelley Brownell, RSW, BSW, Acting Program Manager - Administrator This consent is valid for one year unless revoked in writing by the person giving consent. PCC- Consent to Share Information Form C A05E SEP/10 Page 1 of 1

6 TO: District Office Supervisor Ministry for Children and Families PRIOR PRIOR CONTACT CONTACT CHECK REQUEST CHECK REQUEST Applicant s Full Name and Applicant s Full Name Other persons living in our home over the age of 19 years are: Full Name Full Name Applicant s Signature Applicant s Signature Date Date Address Telephone The above have applied to Family Services Adoption Agency to process an application to adopt. Enclosed is our consent to disclose information. Would you kindly complete the Results of Prior Contact Check (Ministry form: CF2632) and return the form to: Family Services of Greater Vancouver Licensed Adoption Agency # E. Broadway, Vancouver, BC V5N 1W1 Phone: (604) Fax: (604) A05G - PCC Request SEP/10 Page 1 of 1

Ministry of Children and Family Development RESULTS OF PRIOR CONTACT CHECK To: Name of licensed adoption agency: FAMILY SERVICES OF GREATER VANCOUVER Licensed Adoption Agency #301 1638 E.

7 Ministry of Children and Family Development RESULTS OF PRIOR CONTACT CHECK To: Name of licensed adoption agency: FAMILY SERVICES OF GREATER VANCOUVER Licensed Adoption Agency # E. Broadway, Vancouver, BC V5N 1W1 Tel: Fax: The Ministry of Children and Family Development has completed a search of its records regarding the prospective adoptive parent: Last Name: Given Names: Also known as (include maiden or previous names): : FOR MINISTRY USE ONLY With the information provided the Ministry has no information regarding the suitability of the applicant to adopt. The Ministry has information regarding the applicant and has obtained their consent to disclose this to the above agency (see attached copy of Consent to the Disclosure of Information and a summary of the information). The Ministry has information regarding the applicant, which he/she has declined to share. Social Worker s signature: Print Name: Date: Supervisor signature: Print Name: Date: Office Address: Results of PCC 2014 Page 1 of 1

LEAD IN DRINKING WATER REPORT

181 US Hwy 46 Mine Hill, NJ 07803 (908) 654-8068 (800) 783-0567 Fax 908-654-8069 LEAD IN DRINKING WATER REPORT Performed At: Montrose School 356 Clark St., South Orange, NJ 07079 Performed For: South Orange