Guest Screening Questionnaire
Rooms of Refuge
Date of Application
/
Month
/
Day
Year
Date
Staff Member:
VCM #:
First Name
Middle
Last
Check all that apply:
Staying in Newaygo County
Working in Newaygo County
Children Attend School in Newaygo County
Phone
Format: (000) 000-0000.
DOB
Race
Sex:
Male
Female
Number of minor children who will be staying with you
Spouse
Complete if it applies
First Name
Middle
Last
Phone
Format: (000) 000-0000.
DOB
Race
Sex:
Male
Female
Do you give Love INC consent to run criminal background checks including but not limited to Ichat and the National Sex Registry?
Yes
No
Signature
Have you ever been charged or convicted of a sex crime?
Yes
No (Ineligible)
Have you ever been charged or convicted of crimes committed against children?
Yes
No (Ineligible)
Have you ever been charged or convicted of a violent crime?
Yes
No
If yes, please describe the nature of the charge(s):
Do you currently have any charge(s) pending in any state?
Yes
No
If yes, please describe the nature of the charge(s):
Have you ever been asked to leave a shelter?
Yes
No
If yes, how long ago and what were the circumstances?
Current Situation:
Submit
Should be Empty: