Ronald McDonald House Charities of Pittsburgh ("RMHC") places a high value on the safety and welfare of its residents and their families. RMHC evaluates
all individuals applying for temporary residence at RMHC in accordance with applicable federal and state laws and its current policies and practices. One of the ways in which RMHC evaluates applicants is by conducting criminal history background checks on all individuals (18 years old or older) applying for temporary residence at RMHC. In accordance with applicable law, RHMC may use the information it obtains from a criminal history report to deny an application for temporary residence. Each family member (18 years old or older) who intends to apply for temporary residence must separately fill out this form and the Authorization Form to Obtain a Criminal History Report. Once we receive the completed forms, RMHC will engage a consumer reporting agency to conduct a background check, including criminal history report. Thereafter, RMHC is authorized to obtain consumer reports at any time during a period of temporary residence pursuant to the Authorization Form to Obtain a Criminal History Report.
If RMHC considers any information in the Criminal History Report when making a temporary residence decision that directly and adversely affects you, you will be provided a copy of that report in accordance with the Fair Credit Reporting Act. A summary of your rights under the Fair Credit Reporting Act is attached as Addendum A to the Authorization Form to Obtain a Criminal History Report.
To assist RMHC in obtaining criminal history information, please truthfully and completely answer the following question:
Have you ever been
convicted of ANY misdemeanor (other than moving vehicle or parking violations) or felony? For purposes of this inquiry, the word "convicted" includes, without limitation, pleading guilty, pleading no contest, or nolo contendere, or having a judicial finding of guilt.
If Yes, please list the criminal offense, the date(s) of the conviction or other disposition and where (city, state, country) the conviction or other disposition took place.
RMHC, in its sole discretion, will determine whether your criminal record may threaten an individual’s health, safety, welfare, and ability to peacefully enjoy the RMHC facility and, therefore, result in your application for temporary residence being denied or your temporary residence being terminated. You are required to immediately notify RMHC’s Family Services Director if your answer to the above-referenced questions is inaccurate or changes.
I certify that all of the above-provided information is accurate, complete and can be verified. I agree and understand that any falsification, misrepresentation, or omission may disqualify me from seeking temporary residence at RHMC; or if temporary residence already has been granted, then it will subject me to immediate expulsion from RMHC whenever the falsification, misrepresentation or omission is discovered. I also understand that while RMHC will obtain criminal history background information on potential temporary residents, it cannot and does not guarantee the personal safety of any temporary resident, guest, visitor, or staff member.
Authorization to Obtain Criminal History Background
The undersigned (“me”, “I”), UNDERSTANDs that, pursuant to the Fair Credit Reporting Act (“FCRA”), Ronald McDonald House of Charities of Pittsburgh (“RMHC”) will obtain a consumer report on me in the form of a criminal history report for the purposes of determining whether I am eligible for temporary residency at RMHC.
I UNDERSTAND that a consumer report is any report (whether written, oral or through other communication) of any information by a consumer reporting agency bearing on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living that is used or expected to be used or collected in whole or in part for the purpose of evaluating me for purposes of my application for temporary residency at RMHC.
I UNDERSTAND that RMHC will notify me upon my request of the name and address of the consumer reporting agency that furnished the report to it about me.
I hereby AUTHORIZE RMHC to obtain a criminal history report on me in connection with my application for temporary residency and, if temporary residency is granted, in connection with my continued participation in RMHC’s temporary residency program.
I ACKNOWLEDGE AND AFFIRM that I have received a summary of my rights under the FCRA (Addendum A).
Full Name (print First Middle Last)*
Date of Birth (MM/DD/YYYY)*
Other Names Used / Dates of Use (e.g. Maiden name)*
Social Security Number*
Name of Patient Child*
Relationship to Patient Child*
Date of Housing to Begin*
Do you currently live or have you ever lived in the state of Kentucky?*