Background Check Form - Childrens Advocacy Center Of Hidalgo Page 2
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3Texas Dept of Family
Form 1601
PERMISSION TO ALLOW CAC PROGRAM TO REQUEST
and Protective Services
May. 2012
CHILD ABUSE/NEGLECT
CENTRAL REGISTRY and DPS CRIMINAL HISTORY CHECK
REQUIRED IDENTIFYING INFORMATION ON SUBJECT OF REQUEST - The requester must provide all of this
information in order for a check to be made:
First Name
Middle Name
Last Name
Other names or spellings used (married, maiden, alias, etc.) - First, Middle, Last (continue on back as needed)
E-mail Address (optional)
Current Residence Street Address
City
County
State
Zip Code
Residence Telephone No. (A/C)
Date of Birth
SSN
:
Gender
Male -
Female
Race (check all applicable)
Ethnicity (check one, only)
Am Indian/AK Native
Nat Hawaii/Pacis
Hispanic
Asian
White
Not Hispanic
Black
Unable to Determine
Unable to Determine
Texas
List all addresses you have resided in
:
I am the person listed above. The information in this document is correct and I am a prospective or current volunteer,
employee or board member of a Children’s Advocacy Center (CAC) program. I agree to update the CAC program of
any changes to the information above.
I grant permission to the CAC program to request a Child Abuse/Neglect Central Registry and a Texas Department of
Public Service Criminal history check as well as any subsequent checks so long as I am active with the CAC program.
I authorize DFPS to transmit the results of this background check via e-mail and I acknowledge that DFPS cannot
guarantee that information transmitted electronically is secure and accessible only to approved parties.
I understand that the information I am providing will be part of any request and that providing false information is a
violation of Texas Penal Code Section 37.10.
Signature: _______________________________
Date of Consent: _________________________
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