CSO1104A (516) ARIZONA DEPARTMENT OF CHILD SAFETY RESPONSE BY

cso-1104a (5-16) arizona department of child safety response by relative or person having a significant relationship with the child the

CSO-1104A (5-16) ARIZONA DEPARTMENT OF CHILD SAFETY
RESPONSE BY RELATIVE OR PERSON HAVING A
SIGNIFICANT RELATIONSHIP WITH THE CHILD
The Arizona Department of Child Safety (DCS) needs to know if you want
to provide contact, connection or support for the child(ren) and/or be
considered as a placement option for the child(ren). (Please print or
type all information.)
I,
 
understand that
Your name and relationship to the child(ren)
 
is/are currently in the custody of DCS.
Child(ren)’s name(s)
1. I would like to discuss the child(ren) and their needs with the
Child Safety Specialist.
Yes No
2. I wish to be involved in the life of the child(ren) by:
 
3. I wish to be considered as a possible placement option.
Now In the future Unsure Do not want to be considered
If you have information about other relatives or adults who may want
to help, please provide their name and contact information, such as
address, phone number and email address:
 
 
Your Signature
Date
Your contact information:
 
 
Name
Phone No.
 
Address (No., Street, Apt. No., City, State, ZIP Code)
Please return this form within 30 days of the date of this letter so
you can be included in the planning for the child(ren).
 
 
Child Safety Specialist's Name
Phone No.
 
Address
You may email or fax the completed form to:  
Child Safety Specialist’s email address or fax no.
You may download this form at:
https://dcs.az.gov/sites/default/files/DCS-Forms/CSO-1104A.doc
Equal Opportunity Employer/Program • Under Titles VI and VII of the
Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act
of 1973, the Age Discrimination Act of 1975, and Title II of the
Genetic Information Nondiscrimination Act (GINA) of 2008; the
Department prohibits discrimination in admissions, programs, services,
activities, or employment based on race, color, religion, sex,
national origin, age, disability, genetics and retaliation. The
Department must make a reasonable accommodation to allow a person with
a disability to take part in a program, service or activity. For
example, this means if necessary, the Department must provide sign
language interpreters for people who are deaf, a wheelchair accessible
location, or enlarged print materials. It also means that the
Department will take any other reasonable action that allows you to
take part in and understand a program or activity, including making
reasonable changes to an activity. If you believe that you will not be
able to understand or take part in a program or activity because of
your disability, please let us know of your disability needs in
advance if at all possible. To request this document in alternative
format or for further information about this policy, contact your
local office; TTY/TDD Services: 7-1-1. • Free language assistance for
department services is available upon request. • Disponible en
español en línea o en la oficina local.