Background Check Authorization
Name
First Name
Middle Name
Last Name
Today's Date
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Month
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Day
Year
Date
Birthdate
*
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Month
-
Day
Year
Date
Social Security Number
*
Format: XXX-XX-XXXX
Confidential Information
Answering "YES" to any of these will require an explanation
Have you ever been convicted on any crime against children or other persons?
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Yes
No
Explain
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Have you ever been convicted of crime relating to financial exploitation if the victim was a vulnerable adult?
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Yes
No
Explain
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Have you ever been convicted of crimes related to drugs as defined in RCW 43.43.830?
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Yes
No
Explain
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Have you ever been found in any dependency action under RCW 13.34.040 to have sexually or physically abused any minor?
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Yes
No
Explain
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Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person or to have abused or financially exploited any vulnerable adult?
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Yes
No
Explain
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Have you ever been found by a court in a protection proceeding under chapter 74.34 RCW, to have abused or financially exploited any vulnerable adult?
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Yes
No
Explain
*
To ensure both your safety and the safety of the children in your care, please speak with a Ministry Staff Member if you have concerns or special meeds related to HIV/AIDS, blood disorders or hepatitis. Thank you.
Applicant's Statement
The information contained in this application is correct to the best of my knowledge. I authorize any references, churches, or other organizations listed in this application to give you any information they may have regarding my character and fitness for children's/minor's services, and I release all such references from liability for any damage which may result from furnishing such evaluations to you. I understand the personal information will be held confidentially by the professional church staff. I also understand that there will be a background check conducted.
Applicant's Signature
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Today's Date
*
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Month
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Day
Year
Date
Submit
Should be Empty: