Authorization Form (Page 2 of 2) in pdf

Background Check Form

Please print.

First Name: ______________________ Middle Name: ______________________ Last Name: ___________________

Alias/Nickname___________________________________________________________________________________

Date of Birth (MM/DD/YY) _____________________ Sex: _______ Social Security No.______.________._________

ALL

The above information is required for

volunteers.

Volunteers age 18 and over - A background check is required on all applicants over 18 years of age. To do a background check, we

must have your permanent address and your prior addresses from the past five years.

Current Address

Street: _______________________________________

City: ________________ State: ______ ZIP: ________

Permanent Address

Address for the Past Five Years

Street: _______________________________________

Street: _________________________________________

City: ________________ State: ______ ZIP: ________

City: __________________ State: ______ ZIP: ________

Other than minor traffic offenses in which the fine imposed was $100 or less, have you ever:

Been convicted of a crime (misdemeanor or felony)?

Received a probated sentence (including deferred adjudication) for an alleged crime?

Been assigned a probation officer?

Plead guilty, no contest, or nolo contendere to an alleged crime?

Been made the subject of a complaint or investigation concerning alleged child or elder abuse or neglect?

Been listed on the employee disqualification list maintained by the Missouri Division of Social Services, or any other

state?

Yes If the answer is YES, specify the offense, date, place, and court which has a record thereof.

________________________________________________________________________________________________

By signing this form, I agree to the following:

I authorize the release of any criminal history records and information to St. Louis Children’s Hospital.

I understand that my volunteer assignment is contingent upon a clean background check.

I understand that St. Louis Children's Hospital will conduct a child abuse screening on me through the Division of

Family Services and a criminal background check.

I release from all liability or responsibility all persons or organizations requesting or supplying information regarding

my character and qualifications.

I have provided information, which is true and complete to the best of my knowledge.

If I have provided false information, I may not be allowed to volunteer or I may be dismissed in the future.

Signature of Applicant: ___________________________________________ Date: ___________________________

Authorization Form Page 2