Felony conviction exception request

It is the policy of RMHC-KC that any person with a felony conviction is ineligible to stay unless an exception has been granted. Please complete the following information in full detail; RMHC-KC will use the provided information to decide if an exception will be granted. 

If you need assistance completing this form, please call 816-541-8460.

Please note: RMHC-KC will not consider an exception for the following: a criminal history of violence (including assault), sexual misconduct, or abuse/neglect of a child.
* Your Name (First/Middle/Last Required)
* Date of Birth mm/dd/yyyy
* Relationship to patient
* Are you the primary caregiver of the patient?
Yes No
* Please list all criminal convictions, misdemeanor(s) and/or felonies.
* Sentence/Punishment
* Date of Conviction (Month/Year)
* Are you still on parole or Probation?
* When were you released from jail/prison?
* 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.
* Who is filling out this form?
* This should always be the person with felony.
* What's the best way to contact you?
I certify that the above information is true and correct.