AGAPE

AGAPE
RELEASE/AUTHORIZATION FOR BACKGROUND INVESTIGATION
(In keeping with TCA 37-1-414, AGAPE is required to conduct background checks on all employees, foster and adoptive parents and volunteers in order to safeguard children)

I hereby acknowledge that as a condition of my employment or independent contractor application with AGAPE, or as a condition of my application as a volunteer, adoptive parent or foster parent, for the purpose of verifying the accuracy of criminal violation information contained on my application and as required by policy, AGAPE may conduct any or all of the following investigative measures in regard to my application or ongoing employment or service with AGAPE.
- County and local criminal record checks.
- Fingerprint check, conducted by the Dept. of Children's Services through the TBI/FBI.
- National Sex Offender Registry Check and/or state Sex Offender Registry Checks
- Dept. of Health Vulnerable Persons Abuse Registry Checks
- Drug Offender Registry Checks
- Felony Offender Registry Checks
- TN DCS Database child abuse/neglect search
- Out of State child abuse/neglect search
- Motor vehicle record checks
- Drug Screen
Reason for submitting release:*

EmploymentAdoptive ParentFoster ParentVolunteerOther
Home Study Writer or Case Manager*
Last Name (legal)*
First Name (legal)*
Middle Name (legal)
Social Security #*
Birth/Maiden Name
All Other Formal Names
Date of Birth*

MonthDayYear
Date
City/State of Birth*
Sex*
Race*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Tennessee Driver's License Number:*
License Expiration Date:*
Name and Title of Agape Contact*
Current Residence - Street Address*
City/State/Zip*
County*
OTHER Residence during past 5 years - Street Address
City/State/Zip
County
OTHER Residence during past 5 years - Street Address
City/State/Zip
County
If additional space is needed for prior addresses, please include here:
- AGAPE is a subcontractor of OmnVisions, Inc. and enters their foster homes into the Department of Children's Services system in order to serve children in AGAPE foster homes that are in the legal custody of the state. I understand that the results of my background and investigative checks will be released to the Department of Children's Services and to OmniVisions, Inc.
- I understand that this information may also be viewed by state licensing or accreditation bodies auditing the agency and may be released without authorization to the court by court order.
- I understand that the information contained in these background checks will not be re-disclosed to another agency outside of AGAPE excluding those named above once received except as authorized by my signature on a release form specifically naming the parties to whom I give permission to release.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

AGAPE

RELEASE/AUTHORIZATION FOR BACKGROUND INVESTIGATION