Complete all applicable fields and provide all former names and residences from the past five years. Sensitive information is collected only as needed for identity verification, required background checks, registry searches, or legally required reporting.

• AGAPE is a contractor with the Tennessee Department of Children's Services and enters foster homes into the DCS system to serve children in AGAPE foster homes who are in state custody; my background-check results will be released to DCS.
• I understand this information may be viewed by state licensing or accreditation bodies auditing the agency and may be released to a court if required by court order.
• AGAPE will treat background-check information as confidential and will not re-disclose it except to DCS, authorized licensing or accreditation bodies, a court when required, or another party specifically authorized by my signed release.
• I authorize AGAPE, as a condition of my application or ongoing employment or service, to verify the accuracy of information I provide and to conduct required background and investigative checks for employment, independent contractor, volunteer, adoptive parent, or foster parent purposes.

These checks may include any or all of the following:

♦ County and local criminal record checks ♦ Fingerprint check by DCS through TBI/FBI ♦ National and/or state Sex Offender Registry checks ♦ Vulnerable Persons Abuse Registry checks

♦ Drug and Felony Offender Registry checks ♦ TN DCS child abuse/neglect database search ♦ Out-of-state child abuse/neglect search ♦ Motor vehicle record check and drug screen

This authorization expires 60 days after the date of signature unless revoked earlier in writing.