Host family criminal background check authorization form

A criminal background check must be completed for anyone living in the host family household who will be 18 years or older during the school year. Please complete the information requested below for each household member meeting this criterion.

There was a problem with your submission. Please correct the issues below

Contact Information

Host Family Name

Family Member Name

First Name *

Middle Initial *

Last Name *

Suffix

(Example - Jr., III,)

Mailing Address

Street Address *

State *

City *

Zip *

Phone Number

Email Address

Personal Information

Maiden or Married Names

List any previous last names - separated by a comma.

Date of Birth *

Background Check Questions

Have you ever been charged with or investigated for sexual abuse or sexual harassment of another person? *

Yes No

Have you every been convicted of a crime, other than a minor traffic offense? *

Yes No

Have you ever entered a plea of guilty or a plea of "no contest" (nolo contendere)? *

Yes No

Has any court ever deferred further proceedings without entering a finding of guilty and place you on probation for any crime other than a minor traffic violation? *

Yes No

Authorization

By typing your name and the date below, you are granting Mt. Blue Regional School District / RSU 9 staff permission to run your Criminal Background Check for the purpose of being considered as a Host Family for Mt. Blue High School's International Student Program.

Signature *

Date *

* Required Fields

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