Disclaimer Form - Saint Thomas Regional School
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1DISCLAIMER FORM / BACKGROUND CRIMINAL INVESTIGATION CHECK
DISCLAIMER FORM / BACKGROUND CRIMINAL INVESTIGATION CHECK
DISCLAIMER FORM / BACKGROUND CRIMINAL INVESTIGATION CHECK
Full Name:
_______________________________________
_______________________________________
Maiden Name: _______________________
n Name: _______________________
(First and Last)
Date of Birth:
________________________________
________________________________
POSITION
(SELECT ONE ONLY)
Name of
Parish
Parish
School
School
Agency: ____________________________
___________________________________________
:
City/Town: ___________________________________________
________________
POSITION:
Priest_____
Priest_____
Deacon_____
Deacon_____
Deacon Candidate______
Seminarian ____
____
Transitional Deacon_____
Transitional Deacon_____
Employee_____
Volunteer _____
EMPLOYEES ONLY:
Principal/Vice Principal_____
Principal/Vice Principal_____
Salaried Teacher/Substitute Teacher_____
Teacher/Substitute Teacher_____
Other-Salaried Employee_____
CAL_____
VOLUNTEERS ONLY: CAL_____
Catholic Scouting_____
Catholic Scouting_____
Other_____
SECONDARY POSITION
SECONDARY POSITION (if applicable)
Name of
(SELECT ONE ONLY)
Parish
Parish
School
School
Agency: ____________________________
___________________________________________
:
City/Town: ___________________________________________
________________
POSITION:
Priest_____
Priest_____
Deacon_____
Deacon_____
Deacon Candidate______
Seminarian ______
Seminarian ______
Transitional Deacon_____
Transitional Deacon_____
Employee_____
Volunteer ____
EMPLOYEES ONLY:
Principal/Vice Principal_____
Principal/Vice Principal_____
Salaried Teacher/Substitute Teacher_____
her/Substitute Teacher_____
Other-Salaried Employee_____
CAL_____
VOLUNTEERS ONLY: CAL_____
CAL_____
Catholic Scouting_____
Catholic Scouting_____
Other_____
DISCLAIMER
I__________________________________________________ hereby direct and authorize the Bureau of Criminal Identification of the
I__________________________________________________ hereby direct and authorize the Bureau of Criminal Identification of the
I__________________________________________________ hereby direct and authorize the Bureau of Criminal Identification of the
Department of Attorney General for the State of Rhode Island to make available to
Department of Attorney General for the State of Rhode Island to make available to the Diocese of Providence
the Diocese of Providence any criminal record that
the Bureau of Criminal Identification has on file in reference to me.
the Bureau of Criminal Identification has on file in reference to me. I hereby waive and release any and all manner of actions, cause of
I hereby waive and release any and all manner of actions, cause of
actions, and demands of every kind, nature and description, arising from any release of criminal records and request
actions, and demands of every kind, nature and description, arising from any release of criminal records and requests there from,
actions, and demands of every kind, nature and description, arising from any release of criminal records and request
whatsoever against the State of Rhode Island, Bureau of Criminal Identification, the Attorney General, and employees of the A
whatsoever against the State of Rhode Island, Bureau of Criminal Identification, the Attorney General, and employees of the Attorney
whatsoever against the State of Rhode Island, Bureau of Criminal Identification, the Attorney General, and employees of the A
General’s Office in both law and equity which I may now have or in the future may have.
General’s Office in both law and equity which I may now have or in the future may have.
___________
___________________________
Signature of Applicant
Signature of Applicant
Sworn to before me in the City of _________________________________
n the City of _________________________________State of ___________________
State of ___________________ this ______ day of
_____________________, 20__
___________________________
Notary Public Commission Expires:
NOTE: LEGIBLE copy of government photo identification with date of birth must accompany this Disclaimer. (Examples
: LEGIBLE copy of government photo identification with date of birth must accompany this Disclaimer. (Examples
: LEGIBLE copy of government photo identification with date of birth must accompany this Disclaimer. (Examples – license, passport,
Governmental ID) please return disclaimers to your Parish, School or
please return disclaimers to your Parish, School or Agency.
Office of Education & Compliance
Office of Education & Compliance • 80 St. Mary’s Drive • Cranston, RI 02920
Cranston, RI 02920
October 2008
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