Background Check & Consent Form

(All information gathered by River of Life is kept confidential)

This application is specific to you. Every family member must complete their own application.

Legal Name

First Name

Last Name

Middle Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

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REQUEST FOR BACKGROUND CHECK

River of Life requests that the Department of Social Services Child Protective Services and/or third party investigator as necessary conduct the following inquiry: Disclosure I have been informed that the Department of Social Services Child Protective Services and/or third party investigator will be asked to conduct a background check. I understand that I will be the subject of this background check for purposes of my employment/volunteering to determine whether I have been convicted of any crime. I have the right to be informed of the response to the request for a background check and to obtain a copy of the report, or any record that forms the basis of the report, from the requesting party. I understand that I have the right to challenge the accuracy and completeness of any information contained in the report or record under the relevant information provisions of the Data Practices Act. I understand that I have the right to be informed by River of Life if my application has been denied because of the report received. I understand that I have the right not to be required either directly or indirectly to pay the cost of the background check. Background Check Information I UNDERSTAND MY RIGHTS AS STATED ABOVE AND AGREE TO A BACKGROUND CHECK.

Social Security Number

Birthday