Ronald McDonald House Charities of Greater Cincinnati (“RMHC”) conducts a criminal history background check on all individuals (18 years old or older) applying for temporary residence at RMHC. In selecting family members for temporary residence, RMHC screens family behavior and an individual’s suitability for temporary residence among other families. A criminal conviction record which reveals behavior that may adversely affect another individual’s (e.g., other temporary residents, guests, staff, volunteers) health, safety, welfare and ability to peacefully enjoy the RMHC facility shall result in your application for temporary residence being denied. For example, and without limitation, convictions of violent crimes, domestic violence, child abuse, sex offenses, illegal drug activity, and burglary.

This form includes a Criminal History Background Report Authorization link for you to review and sign. Each family member or overnight visitor (18 years old or older) must separately fill out this form and the Criminal History Background Report Authorization form. Once we receive the completed form, RMHC will have an independent third party conduct a criminal history background check.

If you have any questions about this process please contact the manager on duty at 513-559-4692

To assist RMHC in obtaining criminal history background check information, please truthfully and completely answer the following questions:

* Have you ever been convicted of ANY misdemeanor or felony? For purposes of this inquiry, the word “convicted” includes, without limitation, pleading guilty, pleading no contest, or having a judicial finding of guilt.

If yes, please list the criminal offense, the date(s) of the conviction and where (city, state, country) the conviction took place.

* Have you been arrested for any misdemeanor or felony in the last 3 years?

If yes, please list the criminal offense, describe the circumstances leading to the arrest, the date(s) of the arrest and where (city, state, country) the arrest took place.

* Do you currently have any open cases with Child Protective Services or have any children ever been removed from your care due to a Child Protective Services investigation?

If yes, please explain:

RMHC, at 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. You are required to promptly notify RMHC’s Guest Services Manager if your answer to the above‐referenced questions needs to be updated.

By electronically signing below, 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 RMHC; 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.

* Type your full legal name (First/Middle/Last):

* Date of Birth:

* Ethnicity:

* Gender:

* Do you currently live or have you ever lived in the state of Kentucky?

If you responded yes to the previous question, enter your Social Security number below:

* Phone Number:

* Email Address:

* Name of Patient Child

* Relationship to patient