Background Check Authorization Form

Ronald McDonald House Charities of The Miami Valley Region (“RHMC-MVR”) conducts a criminal history background check on all individuals (18 years old or older) applying for temporary residence at the Ronald McDonald House of Dayton. In determining eligibility for temporary residence, RHMC-MVR screens family behavior and an individual’s suitability for temporary residence among other families. A criminal conviction record which reveals behavior that may adversely affect another individual’s (e.g., other temporary residents, guests, staff, volunteers) health, safety, welfare and ability to peacefully enjoy the RHMC facility shall result in your application for temporary residence being denied. For example, and without limitation, convictions of violent crimes, domestic violence, child abuse, sex offenses, illegal drug activity, burglary, and/or identity theft will result in rejection of your application.

This form includes a Criminal History Background Report Authorization form for you to review and sign. Each family member or visitor (18 years old or older) who intends to apply for temporary residence must separately fill out this form and the Criminal History Background Report Authorization form. Once we receive the completed form, RMHC-MVR will have an independent third party conduct a criminal history background check.

Ronald McDonald House of Charities of The Miami Valley Region (RMHC-MVR) will attempt to obtain and use a criminal history background “consumer report” from a “consumer reporting agency” when considering your application for temporary residence while your child (or family relation) is receiving medical treatment at Dayton Children’s Hospital, Miami Valley Hospital, or another area hospital. These quoted terms are defined in the FCRA, a law which RMHC-MVR deems to apply to you.[1] As an applicant for temporary residence at our facility, RMHC-MVR is considering you to be a “consumer” with rights under the FCRA.

Please understand that RMHC-MVR solely will obtain a criminal history background report to assist it in determining whether to grant you temporary residence. RMHC-MVR is not obtaining a “consumer report” for any other information and will NOT be conducting a credit check.

If RMHC-MVR considers any information in the criminal history background report when making a temporary residence decision that directly and adversely affects you, you will be provided with a copy of that report. You also may contact the Federal Trade Commission about your rights under the FCRA as a “consumer” with regard to “consumer reports” and “consumer reporting agencies.”

To assist RMHC-MVR in obtaining criminal history background check information, please truthfully and completely answer the following question:

Have you ever been convicted of ANY misdemeanor (other than moving vehicle or parking violations) or felony? For purposes of this inquiry, the word “convicted” includes, without limitation, pleading guilty, pleading no contest, or having a judicial finding of guilt.*

YesNo

If Yes, please list the criminal offense, the date(s) of the conviction and where (city, state, country) the conviction took place.

Have you been arrested for any misdemeanor or felony involving violence,domestic violence, child abuse, illegal drug activity, sex offenses, burglaryand/or identity theft in the last 3 years?*

YesNo

If Yes, please list the criminal offense, describe the circumstances leading tothe arrest, the date(s) of the arrest and where (city, state, country) thearrest took place.

To assist you in truthfully and completely answering this form, please be advised your application will be in jeopardy if you have been convicted of any of the following criminal offenses (whether or not the offense may have been labeled in another way in your state or country of residence). This list is not all-inclusive. For a full list of offenses for which you may be turned away you may contact RMHC-MVR Operations

·        Murder or Aggravated Murder
·        Public Indecency
·        Medicaid Fraud
·        Voluntary Manslaughter
·        Felonious Sexual Penetration
·        Securing Writings by Deception
·        Assault or Felonious or Aggravated Assault
·        Prostitution
·        Insurance Fraud
·        Failing to Provide for a Functionally Impaired Person
·        Disseminating Matter Harmful to Juveniles
·        Receiving Stolen Property
·        Aggravated Menacing
·        Pandering Obscenity
·        Domestic Violence
·        Kidnapping
·        Pandering Obscenity Involving a Minor
·        Prohibition of Conveyance of Certain Items of Detention Facility
·        Abduction
·        Pandering Sexually Oriented Matter Involving a Minor
·        Carrying Concealed Weapons
·        Extortion
·        Illegal Use of a Minor in Nudity-Oriented Material or Performance
·        Having Weapons While Under Disability
·        Coercion
·        Adulteration of Food
·        Improperly Discharging Firearm at or into Habitation or School
·        Rape
·        Robbery or Aggravated Robbery
·        Corrupting Others with Drugs
·        Sexual Battery
·        Burglary or Aggravated Burglary
·        Trafficking Charges
·        Gross Sexual Imposition
·        Breaking and Entering
·        Drug Abuse
·        Sexual Imposition
·        Theft or Aggravated Theft
·        Identity Theft
·        Importuning
·        Unauthorized Use of a Vehicle
·        Permitting Drug Abuse
·        Voyeurism
·        Unauthorized Use of Property
·        Deception to Obtain a Dangerous Drug
·        Illegal Processing Drug Document
·        Driving Under the Influence
·        Importuning/Soliciting a Minor for Sex

RMHC-MVR, in its sole discretion, will determine whether your criminal record may threaten an individual’s health, safety, welfare, and ability to peacefully enjoy the RMHC facility and, therefore, result in your application for temporary residence being denied. You are required to promptly notify RMHC-MVR’s Guest Services Manager if your answer to the above-referenced questions needs to be updated.

RMHC-MVR will in addition make an overall decision whether the rest of your family will be eligible to stay based on their individual checks.

* * *

I certify that all of the above-provided information is accurate, complete and can be verified. I agree and understand that any falsification, misrepresentation, or omission may disqualify me from seeking temporary residence at RHMC-MVR; or if temporary residence already has been granted, then it will subject me to immediate expulsion from RMHC-MVR whenever the falsification, misrepresentation or omission is discovered. I also understand that while RMHC-MVR will obtain criminal history background information on potential temporary residents, it cannot and does not guarantee the personal safety of any temporary resident, guest, visitor, or staff member.

AUTHORIZATION

By signing below, I knowingly and voluntarily authorize the Ronald McDonald House of Charities of The Miami Valley Region (“RMHC-MVR”) to obtain a criminal history background report from a “consumer reporting agency” and to consider that report when determining whether to grant me temporary residence at RMHC. I understand I have rights under the FCRA, including the rights discussed in the FCRA Summary of Rights, which has been provided to me along with this Authorization form. This Authorization shall remain on file and shall serve as ongoing authorization for RMHC to obtain criminal history background reports on me when I apply for temporary residence at RMHC. I also acknowledge receiving a written Summary of Rights under the FCRA along with this Criminal History Background Report Authorization form.

Name*

First NameLast Name

Previous Name

First NameLast Name

Birthday*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

Relationship to Patient*

Name of Patient*

Facility Patient is Receiving Treatment

Signature*

Clear

Date signed*

Date