CHILD MALTREATMENT FORM INFORMATION
1. Reason for registry check: None of the above applies, but you would like a registry check.
2. Organization Requesting the Report: Havana Assembly of God
3. Representative Name: Crystal Goodwin
4. Mailing Address: P.O. Box 43 Havana, AR 72842
5. Phone Number: 479-476-2411
6. Email Address: havanaassemblyofgod@gmail.com
1. Reason for registry check: None of the above applies, but you would like a registry check.
2. Organization Requesting the Report: Havana Assembly of God
3. Representative Name: Crystal Goodwin
4. Mailing Address: P.O. Box 43 Havana, AR 72842
5. Phone Number: 479-476-2411
6. Email Address: havanaassemblyofgod@gmail.com
MANDATED REPORTER INFORMATION:
1. Register for an account
2. Mandated Reporter Category: Other
3. Specify: Church Volunteer
4. Name of Employer: Havana Assembly of God
ONCE FINISHED, UPLOAD THE CERTIFICATE PDF BELOW
1. Register for an account
2. Mandated Reporter Category: Other
3. Specify: Church Volunteer
4. Name of Employer: Havana Assembly of God
ONCE FINISHED, UPLOAD THE CERTIFICATE PDF BELOW