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Felony conviction exception request
A criminal background check is performed by RMHC-KC staff on all referred guests. Our policy is that any person with a felony conviction is ineligible to stay, unless an exception has been granted. If you would like to request an exception, please complete the following form, in full detail. If you need assistance completing this form, please call 816-541-8460. Please note: Without exception, no one with a criminal history of violence (including battery and assault), sexual misconduct or abuse of a child is eligible to stay at the House.
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Patient Name ( First and Last )
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Patient Date of Birth (MM/DD/YYYY)
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Your Name (First/Middle/Last Required)
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Date of Birth mm/dd/yyyy
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Relationship to patient
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Are you the primary caregiver of the patient?
Yes
No
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List your name and all names used by you since your 18th birthday including first, middle and last names for all.
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Please list all criminal convictions, both felonies and misdemeanors.
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Date of Conviction (Month/Year)
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The committee takes many factors into consideration when making their decision. Please give the committee as many factual details as possible in relation your offenses/ charges. The more detail the better. (i.e. dates of conviction, location, time served, etc.)
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Who is filling out this form?
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This should always be the person with felony.
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What's the best way to contact you?
Help Request Sent
Ok
Name of person completing this form
Patient Name ( First and Last )
Phone
Email
Submit
