Admissions: Parent Background Check

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Consent for Parental Criminal Background Check

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Each parent/guardian must submit this form separately.

AUTHORIZATION / WAIVER / INDEMNITY

I hereby give my permission to COVENANT CHRISTIAN ACADEMY to obtain information relating to my criminal history record through the TEXAS DEPARTMENT OF PUBLIC SAFETY, and any other agencies in other states.

I understand that:

The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications and delinquent conduct as committed as a juvenile.
This information will be used, in part, to determine my eligibility for admission with this organization.
As long as I remain a family here, the criminal history records check may be repeated at any time.
State law prohibits Covenant Christian Academy from disclosing details or providing a person with a copy of their own criminal history record.
The criminal history could contain information presumed to be expunged.
The information that I have provided may be verified, if necessary, by contacting any person or organization that may have information regarding me, or by conducting a criminal background check. I hereby release and agree to hold harmless from liability any person or organization that provides information. I also agree to hold harmless Covenant Christian Academy and its officers, directors, employees, and agents.

Name (middle name is required, if none enter "none")*

First Name

Middle Name

Last Name

Social Security Number*

nnn-nn-nnnn

Date of Birth*

Driver's License Number*

State of Issue*

Please scan and upload a copy of your Driver's License (front only)*

No File Chosen

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Years of residence in the state you currently reside

Other states you have resided in the past 10 years

Disclosures
	No	Yes
Do you use illegal drugs?	Disclosures: Do you use illegal drugs? (No)	Do you use illegal drugs? (Yes)
Have you ever been convicted of a criminal offense?	Have you ever been convicted of a criminal offense? (No)	Have you ever been convicted of a criminal offense? (Yes)
Have you ever been charged with child neglect or abuse?	Have you ever been charged with child neglect or abuse? (No)	Have you ever been charged with child neglect or abuse? (Yes)
Has your driver license ever been suspended or revoked?	Has your driver license ever been suspended or revoked? (No)	Has your driver license ever been suspended or revoked? (Yes)
Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of young people?	Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of young people? (No)	Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of young people? (Yes)

If you answered yes to any of the above, please explain each below.

In signing this application, I have read the attached information and apply for admission for my son/daughter to Covenant Christian Academy. I affirm that the information I have given on this form is true and correct.

Signature*

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Signature Date*