Criminal History Information Supplement

Please complete this Criminal History Information Supplement (if you are 18 or older). If you are offered employment or a volunteer position, Holy Spirit Lutheran Church will conduct a criminal history background check. Holy Spirit Lutheran Church shall use these records only in making the initial engagement decision. Further dissemination of the record is prohibited without written permission from the applicant.

Legal Last Name, First Name, Middle Initial

Date of Birth

YYYY

Last 3 digits of your Social Security Number

Gender

Race

Have you ever been convicted of any crime against children or other persons?

RCW 43.43.830(7) “Crime against children or other persons" means a conviction of any of the following offenses: Aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, or third degree assault; first, second, or third degree assault of a child; first, second, or third degree rape; first, second, or third degree rape of a child; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; endangerment with a controlled substance; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; first or second degree custodial sexual misconduct; malicious harassment; first, second, or third degree child molestation; first or second degree sexual misconduct with a minor; commercial sexual abuse of a minor; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony indecent exposure; criminal abandonment; or any of these crimes as they may be renamed in the future.”

If yes, please specify

Have you ever been convicted of crimes relating to drugs under RCW 43.43.830(8)?

RCW 43.43.830(8) “Crimes relating to drugs” means a conviction of a crime to manufacture, delivery, or possession with intent to manufacture or deliver a controlled substance.

If yes, please specify

Have you ever been convicted of crimes relating to financial exploitation if the victim was a vulnerable adult?

RCW 43.43.830(9) “Crimes relating to financial exploitation” means a conviction for first, second, or third degree extortion; first, second, or third degree theft; first or second degree robbery; forgery; or any of these crimes as they may be renamed in the future. RCW 43.43.830(14) “Vulnerable adult” means “vulnerable adult” as defined in chapter 74.34 RCW, except that for the purposes of requesting and receiving background checks pursuant to RCW 43.43.832, it shall also include adults of any age who lack the functional, mental, or physical ability to care for themselves. RCW 74.34.020(22) “Vulnerable adult” includes a person (a) Sixty years of age or older who has the functional, mental, or physical inability to care for himself or herself; or (b) Found incapacitated under chapter 11.88 RCW; or (c) Who has a developmental disability as defined under RCW 71A.10.020; or (d) Admitted to any facility; or (e) Receiving services from home health, hospice, or home care agencies licensed or required to be licensed under chapter 70.127 RCW; or (f) Receiving services from an individual provider; or (g) Who self-directs his or her own care and receives services from a personal aide under chapter 74.39 RCW. RCW 74.34.020(7) “Financial exploitation” means the illegal or improper use, control over, or withholding of the property, income, resources, or trust funds of the vulnerable adult by any person or entity for any person's or entity's profit or advantage other than for the vulnerable adult's profit or advantage.

If yes, please specify

Have you ever been found by a court of law in a protection proceeding under chapter 74.34 RCW, to have abused or financially exploited any vulnerable adult?

If yes, please specify

Have you ever been found in any dependency action under RCW 13.34 to have sexually assaulted or exploited a minor or to have physically abused any minor?

If yes, please specify

Has the Department of Social and Health Services in Washington or any other state ever found that you have physically or sexually abused a child as defined by WAC 388-15-009?

WAC 388-15-009 Child abuse or neglect means the injury, sexual abuse, or sexual exploitation of a child by any person under circumstances which indicate that the child's health, welfare, or safety is harmed, or the negligent treatment or maltreatment of a child by a person responsible for or providing care to the child. An abused child is a child who has been subjected to child abuse or neglect as defined in this WAC.

If yes, please specify

Have you ever been found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor?

If yes, please specify

Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person or to have abused or financially exploited any vulnerable adult?

If yes, please specify

I declare, under penalty of perjury under the laws of the State of Washington, that the statements above are true and correct. I authorize the Church to conduct a criminal background check on me, including a detailed investigation into founded findings and allegations.

Please type name and date below

Certification Concerning Criminal History outside the State of Washington

I declare, under penalty of perjury under the laws of the State of Washington, that I have not been convicted of any criminal offenses against children or other persons, crimes relating to drugs or alcohol consumption, financial exploitation or had findings entered against me concerning such criminal offenses outside the State of Washington.

Please type name and date below