RMHCSWV Background Check Authorization Form

Ronald McDonald House Charities of Southern West Virginia (“RMHC”) conducts a criminal history background check on all individuals (18 years old or older) applying for temporary residence at RMHC. In selecting family members for temporary residence, RMHC screens family behavior and an individual’s suitability for temporary residence among other families. A criminal conviction record that 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 RMHC facility shall result in your application for the 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 the rejection of your application.

This form includes a Criminal History Background Report Authorization form for you to review and sign. EACH family member or overnight 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 will have an independent third party conduct a criminal history background check.

RMHC 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 a Charleston area medical facility. These quoted terms are defined in the Fair Credit Reporting Act (“FCRA”), a law that RMHC deems to apply to you.¹As an applicant for temporary residence at our facility, RMHC is considering you to be a “consumer” with rights under the FCRA.

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

If RMHC considers any information in the criminal history background report when making a temporary residence decision that directly and adversely affects you, you may request 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 in obtaining criminal history background check information, please truthfully and completely answer the following question:

¹ A “consumer reporting agency” is a person or business that, for monetary fees, dues, or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing “consumer reports” to others, such as RMHC. A “consumer reporting agency” bearing on a consumer’s creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics, motor vehicle record, or mode of living that is used or collected for the purpose of serving as a factor in establishing the consumer’s eligibility for the particular purpose at hand. A “consumer report” also may include, without limitation, information about your employment history, educational background, or your criminal history background.

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 ever been arrested for any misdemeanor or felony involving violence, domestic violence, child abuse, illegal drug activity, sex offenses, burglary and/or identify theft in the last 15 years?*

YesNo

If yes, please list the criminal offense, describe the circumstances leading to the arrest, the date(s) of the arrest and where (city, state, country) the arrest 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.

RMHC, 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 the temporary residence being denied. You are required to promptly notify RMHC’s staff if your answer to the above-referenced questions needs to be updated. RMHC 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 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 RMHC; or if temporary residence already has been granted, then it will subject me to immediate expulsion from RMHC whenever the falsification, misrepresentation, or omission is discovered. I also understand that while RMHC 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 Charities of Southern West Virginia (“RMHC”) 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 are available upon request. 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 (signature)*

Date Signed*

Date

Full Name (First, Middle, Last)*

Any Previous Name(s) (e.g., Maiden Name)

Social Security Number*

Date of Birth*

MonthDayYear

Address (No P.O. Box. Physical Address Only)*

Street Address (No P.O. Box. Physical Address Only)

Street Address Line 2

CityState / Province

Postal / Zip Code

County*

Contact Phone Number*

Area CodePhone Number

Name of Patient*

Relationship to Patient*

Hospital Unit*

Date of First Appointment at the Hospital*

Date