Request Form

REQUEST FORM

Under PART X of the Child, Youth and Family Services Act.

Please note, all areas indicated with a “star” must be completed. If you prefer to submit a hard copy request, please use the pdf version of this form which is available here: Request Form_-_Part X CYFSA

I would like to request the following from the Children’s Aid Society of Oxford County:

I request a copy of my personal records held at the Children’s Aid Society of Oxford County

I request a change to my personal information that is held at the Children’s Aid Society of Oxford County

Full Legal Name

Birthdate (MM-DD-YYYY)

Current Address

City/Town

Province

Postal Code

Daytime Phone Number

Evening Phone Number

Your Email

Check below if you require assistance with the completion of this information.

If your request is for access to, or correction of your personal information records, please indicate all other names you may be known by: (150 chars left)

If are making the request for access to personal information as a substitute decision maker, please provide the name of the person requesting their records and the authority (e.g. a custody order) that defines you as the substitute decision maker. (150 chars left)

Please provide a description, as detailed as possible, of records or personal information you are requesting. For example, a period of time, specific incident, etc.

Note: If you are requesting a correction of personal information, please indicate the date the information shows up in your record and the desired correction. You will be notified if the correction is not going to be made by the Society and you may request that the Society attach a “Statement of Disagreement" to your personal information held at the Society. (150 chars left)

Please indicate how you would like to receive your personal record.
(Photo identification will be required at the time you pick up your record.) A photocopy of each page of your record A digital copy (disc) An email with a link to your personal records (password protected and encrypted)

Disclaimer: I agree that my submitted data is being collected and stored by the Children’s Aid Society of Oxford County. Please Note: The Children’s Aid Society of Oxford County must abide by the privacy rules set out in the Child, Youth and Family Services Act, 2017. At the Children’s Aid Society of Oxford County, we are committed to providing you with fast, friendly, easy access to the many services of the Society. In order to assist you, we welcome you to provide your personal information online via our secure server. Any personal information that you give us will be collected, used and disclosed in accordance with law and our privacy policies. If you have any questions about our privacy practices or the collection, use and disclosure of your personal information, please contact Privacy Designate, Alex Wright, at 519-539-6176.

Electronic Signature: Please type your first and last name

Acceptance Checkbox
I understand that checking the box below constitutes a legal signature confirming that I acknowledge and agree to the above Disclaimer.

Date of Submission (MM-DD-YYYY)

Personal Information contained on this form is collected pursuant to PART X of the Child, Youth and Family Services Act and will be used for the purpose of responding to your request. Questions about this collection should be directed to the Privacy Designate at the Children’s Aid Society of Oxford County, Alexandra Wright at 519-539-6176.

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REQUEST FORM

I would like to request the following from the Children’s Aid Society of Oxford County:

Thank you for your submission!