Criminal and Central Registry Check Consent

Consent for Background check

Complete for applicants & respite providers or household members/frequent visitors ages 14 years and older. Disclosure: Background checks cannot be ran unless we also receive a copy of the Driver’s License and Social Security card.

Name: First, Middle, Last*
Maiden Name:
Other Past Names:
Role In Home*
If a FBI Fingerprint needs to be ran; the applicant will have no more than 30 days to complete the FBI checks from the date the initial background check has been ran. The directions to schedule the FBI check will be sent via email (if an address is provided above) at the time the background checks are ran.
Affiliated Home*

Mark "n/a" if you do not have an affiliation to another Circles of Care home.
Address:*
Street Address Address Line 2 City State ZIP Code
County:*
Home Phone:*
Cell Phone:
Email Address*
Date of Birth:*
Month
Day
Year
Age:*
Sex:*
- Male
- Female
TDL#:*
State Issued ID#:
Race/Ethnic Group:*
- Hispanic
- African-American
- Caucasian
- Asian
- Native American
List all other cities in Texas where you have lived in the past:*
Have you ever lived outside the State of Texas?*
- Yes
- No
If "Yes", indicate the states or countries below:
List all out of state addresses you have lived in the last 5 years:
Address City State County
Have you ever been arrested for any reason (including for crimes while driving your car, such as driving while intoxicated [DWI])?*
- Yes
- No
If "Yes", state the crime for which you were arrested and the date:
Note: A background check will be completed on the applicants and any household member 14 years of age and older as well as frequent visitors to the home. Frequent is defined as more than twice in a 30-day period.

The following may preclude any person from being a foster parent, being a household member in the foster home or being a frequent visitor in the foster home; Any misdemeanor or felony such as, offenses against a person, robbery, public indecency, stalking, solicitation of a minor, failure to stop or report aggravated sexual assault of a child, making a firearm accessible to a child, intoxication offenses, any felony and any deferred adjudication of any of the above.

Any other charges a person may have will be evaluated and assessed if we will allow licensure; some of the factors used in our assessment include the type of charge, the length of time since the charge, and the age of the applicant at the time of the charge.
I hereby authorize Circles of Care to be furnished information regarding my Criminal, Central Registry (child abuse), and Driver’s License records. I also understand that if I have previously been licensed by another child placing agency, that information obtained during the application process and home study, including results of these checks that they obtained, must also be obtained from them for study purposes by Circles of Care. In addition, if I leave this agency, any information obtained by Circles of Care will be divulged to any other home licensing agency that requests it in which I have applied for licensure. I understand that this is a standing authorization, and that Circles of Care may recheck my Criminal, Central Registry (child abuse), and Driver’s License records as required by regulations or as circumstances necessitate. I may revoke this permission at any time, in writing, and understand that this may mean the termination of my association with Circles of Care and/or its clients, providers, and other affiliates.
Note: In addition to completing the on-line background check form, it is necessary for us to obtain a copy of your current Driver’s License/State Issued ID and Social Security card in accordance with state law and Circles of Care policy to verify the accuracy of the information provided. A representative will contact you to obtain the necessary documents prior to completing the actual background check.
Applicants Signature*

By entering your name, you are signing the above form and verifying that all information is correct.
Date*
Month
Day
Year
Circles of Care hereby certifies that any and all information obtained from theses record checks of the above named applicant will be kept in strict confidentiality and used solely for the purpose of evaluating the household for child placement.
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Address	City	State	County