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Adult Screening & Background Check

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REACH Kzoo is committed to providing a safe and secure environment for those participating in the educational opportunities provided by our organization and affiliates. We seek to minimize any vulnerability to unwarranted accusation of improper behavior that our organization, members, and employees may experience as they fulfill their duties.  To fulfill these commitments as fully as possible, our board has adopted the following procedures to be used, without exception.

  • At no time will any non-related teen, adult, or couple be alone in a room with two or fewer minors unless the door is open or the minor's adult parent or guardian is present.  All non-classroom areas are monitored by Welcome Center adults in order to prevent one-on-one counseling.
  • Criminal background checks are run by ScreeningOne on all tutors, substitutes, board members, and LEAD service members. 
  • Background check forms are completed for all adult members including parent/guardian/designated responsible adult on the premises in order to provide history of criminal behavior.
  • Should the organization hire a Director or any other employee(s), the applicant(s) would undergo an extensive background check, including an inquiry of the applicant's criminal history.
  • When indicated by our screening procedures, members, or employment candidates who pose a threat to children, youth, or vulnerable adults will be removed immediately from consideration for service or employment anywhere within our organization.
  • Any violators of the above procedures are subject to removal from REACH Kzoo immediately, without opportunity to return. 

We ask that at least one parent from each family complete this form.  If both parents will be involved in fulfilling the parent co-op service commitment, they each need to complete the form. If a parent will be on campus for any reason, a form should be completed.
1. *

Last Name
2. *

First Name
3. *

Middle Name (If none, type NA)
4. *

Date of Birth (MM/DD/YYYY)
5. *

Gender
Female Male
6. *

Ethnicity
7. *

Street Address
8. *

City
9. *

State
10. *

Zip Code
11. *

Home Phone
12. 

Work Phone
13. *

Cell Phone
14. *

Email Address
15. *

Have you ever been known by another name?
16. 

If yes, list names (maiden name / full name) here
17. *

Do you have a current Driver's License? 
18. 

If no, please explain:
19. *

Driver's License Number (if none type NA)
20. *

State in which Driver's License is issued: (If none type NA)

Volunteer Screening

Have you at any time ever:
21. *

Been convicted of, or pled guilty, or no contest to any crime?
22. *

Participated in, or been accused, convicted, or pled guilty, or no contest to abuse or any sexual misconduct?
23. *

Are you aware of having any traits or tendencies that could pose any threat to children, youth, or others?
24. *

Are you aware of any reason why you should not work or be with children, youth, or others?
25. 

If the answer to any of these questions is "yes," please explain in detail in the box below. 
26. *

My electronic signature below serves as consent to this screening and background check as well as my affirmation that the information completed in this form is true and accurate to the best of my knowledge. 
27. *

Date of electronic signature (MM/DD/YYYY):