Access Request For Personal Information *** NOTE: This form should not be used for requests for information related to finalized adoptions. If you are requesting information related to finalized adoptions please visit adoption-disclosure-information to download and complete the Request for Non-Identifying Information form and the Consent for Release of Non-Identifying Information. *** *** NOTE: If your request relates to a court proceeding do not use this form. Contact us for the appropriate form. *** Requester InformationRequester Information -- Name* First Middle Last Birth Name:Other Known Names, Prior Names, Aliases:Date of Birth DD MM YYYY Information Being RequestedI require this information for: A current court proceeding For my own personal use Other (specify): Other Reason you are seeking InformationAre you seeking information from when you were a child? Yes No Seeking records from when you were a childMother's Name* First Middle Last *Please provide only If you are seeking records from when you were a child.Mother's Date of Birth DD MM YYYY Father's Name * First Last Please provide only If you are seeking records from when you were a child.Father's Date of Birth DD MM YYYY Requesting information for:Requester is requesting on behalf of:SelfSelf and Child(ren) - Names and Date of BirthChild(ren) - Names and Date of BirthOther - Explain, Name and Date of BirthSubstitute Decision MakerIf requesting on behalf of someone else, specify authority:Substitute Decision-Maker -- (Explanation required)Executor of the Estate of a Deceased Person -- (Evidence required)Substitute Decision Maker: In accordance with Part X of the CYFSA, decision making authority will need to be determined prior to providing the record of a minor child. Please provide along with this request, brief summary of any parenting order/separation agreement which outlines your custodial status. Please note that the consent of a capable child/youth is required if their parent is seeking access to their personal information. The written consent of any person over the age of 16 years is required to release their information and must be included with your request in order to obtain their information. Substitute Decision-Maker -- Explain (e.g., Custodial Parent, Access Parent, Guardian, Power of Attorney, etc.)*Please Note: You may be asked to provide supporting documentation.Child(ren) or Other - Enter Name and Date of Birth, ExplanationRequest DetailsInformation being sought: I am requesting information for specific dates I am requesting the following specific records I was previously and/or am currently a child in care and am looking for information about this period of time: I was adopted and / or the person I want records about was adopted and I am looking for information about this From Date DD MM YYYY Up to and including Date DD MM YYYY List specific records being requested (Include and name dates if known):Any further details about your request?Have you requested access to these records in the past?NoYesIf Yes, when?Contact InformationFor follow up how do you wish to be contacted? Telephone E-mail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Daytime Phone Number*May we leave a message for you at this number? Yes No Does anyone else share this phone with you? Yes No Email Address* Voluntary Consent to Electronic Communication: *I am consenting to being contacted via email. Please use the above e-mail address to contact me. I acknowledge that sending E-mail over the Internet is not secure, in that it can be intercepted, manipulated and/or retransmitted. Emailing of identity information will only occur with your authorization. Proof of IdentificationTo ensure confidentiality and protect your privacy, WECAS must receive verification of your identity prior to processing this request. Two pieces are requested, at least one of which contains your photo and current address. WECAS will destroy the copy of your identification that you provide for this purpose and it will not be put into CPIN. The documents you will receive will be in the format of an electronic File Hold secure link. If you have concerns about this method of delivery, please discuss with the Clerk assigned. Records provided by WECAS are for the requestors personal use alone and are not to be distributed with any unauthorized persons and shall not be published without appropriate authorization to do so and as prescribed by law. This request is for your personal record, you are not entitled to third party information. Please send this completed form, copies of identification and any parenting order/separation agreement to privacy@wecas.on.ca. Mail or drop off in-person to: The Windsor-Essex Children’s Aid Society 1671 Riverside Drive East Windsor, Ontario N8Y 5B5 Attention: Disclosure Department Δ