Adult Workers with Children, Youth and Vulnerable Adults
Background Check
Email address *
Legal First Name *
Middle Initial
Last Name *
Address *
Phone Number *
Date of Birth *
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Gender *
Please complete the following questions. *
Yes
No
Have you ever been convicted of any crime against children or other persons?
Have you ever been found in any dependency action to have sexually assaulted or exploited any minor or to have physically abused any minor?
Have you ever been found by a court, in a domestic relations proceeding, to have sexually abused or exploited any minor or to have physically abused any minor?
Have you been convicted of the possession, use, or sale of drugs within the last 7 years?
Have you been released from incarceration for a conviction of the possession, use or sale of drugs within the last 7 years?
Within the past 30 days have you abused alcohol, legal or illegal drugs?
Has your driver's license been suspended or revoked within the last 7 years?
Have you ever been convicted of crimes relating to financial exploitation where the victim was a vulnerable adult?
Have you ever been found by a court in a protection proceeding to have abused or financially exploited a vulnerable adult?
Have you ever been licensed by a licensing board that licenses businesses/professions? If yes, explain below.
Have you ever been found by that licensing board, or any other disciplinary board, to have sexually or physically abused or exploited any minor or developmentally disabled person?
Have you ever been found by that licensing board, or any other disciplinary board, to have sexually or physically abuse or explited any minor or developmentally disabled person?
Other than the above matter, is there any fact or circumstance involving you and your background that would call into question your being entrusted with the supervision, guidance and care of young people, vulnerable adults or developmentally disabled persons?
If you answered yes to any of the above, please explain.
I certify that the information I have provided is true and correct. *
Required
Date: *
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