SO Supervision Chaperone Background and Authorization to Release Information

ClientInformationClient’s name: IDOC#:
ProposedChaperone’sStatementofUnderstandingandAuthorization
As an applicant for chaperone with the Idaho Department of Correction (IDOC), I understand that I am providing personal history information to determine my qualifications and suitability
as chaperone with the IDOC.
I understand that I am voluntarily providing personal information such as my name, race, height, weight, gender, date of birth, place of birth, driver’s license number, and social security
number to assist in conducting a background check. By not providing the required information, I am voluntarily suspending, terminating or forfeiting my opportunity as chaperone.
Ihereby authorize any representativeoftheIDOC bearingthis release, orcopy of this release, to obtain any orallrecords and information concerning myself regardless of whether the records
and information are of a confidential nature. The release of files, records, and information may include, but not be limited to, arrest records and criminal files.
I understand that any information obtained in the background, records, or information check will be considered in determining my qualifications and suitability as a chaperone with IDOC.
I also understand that any person, partnership, association, organization, or government agency will not be liable for providing accurate records or information.
Therefore,Ireleaseallpersonsandpartiesfromallclaims,damagesandliabilities thatmayresultfromprovidingthe information requested by an authorized agent from IDOC.Current PhoneNumbers:
Home
Cell
Other
ProposedChaperone’sPrintedName
ProposedChaperone’sSignature
Witnesses(asapplicable)
Date
PPO’sPrintedName
PPO’sSignature
Date
TreatmentProvider’sPrintedName
TreatmentProvider’sSignature
Date
Chaperone Background Questionnaire
Please read and answer all questions below.
Please print. Use black or blue ink.
Be accurate and complete.
All answers are subject to verification
Client'sInformationClient's name:IDOC #: ProposedChaperone’sPersonalInformation
Printortypeyourfulllegalname:
LastFirstMiddle
Listallothernamesyougoby(i.e.,nicknames,maiden,othermarried)What is your relationship to the client?Doyouknowwhatcrime(s)theclientcommitted?If yes,whatis/arethey?List your current homeaddress:List
your current phonenumbers
Home
Cell
OtherStreetCityStateZipProvideyourmailingaddress(ifdifferentfromhomeaddress) ____________________________________StreetCityStateZipAre you a citizen of the United States? Yes No If no,
answer the next questions.
Areyouapermanentresident alienwhois eligiblefor andhas appliedforcitizenship? Yes No
Have you obtained permission from INS to work in the United States? Yes No
Note:Thefollowinginformationyouprovideisrequiredforverificationinconductingthecriminalbackground check:Date of Birth //Place of Birth _______________________________CityStateSocial Security
Number //Driver’s license # State Height Weight Hair Color Eye Color GenderMaleFemaleRaceEmployer’s Name and Address __________________________________________________________Drug or
alcohol use? Yes No If yes, please list______________________________________________Any felony offenses? Yes No If yes, please list______________________________________________Anymisdemeanoroffenses?
YesNoIf yes,pleaselist________________________________________
CertificationofBackgroundInvestigationQuestionnaireAnswers
IdahoDepartmentofCorrection’s(IDOC’s)Statement
Thestatementsand answers that you provided in this background investigationquestionnairearesubject to verification.Anydiscrepancies,misstatements,omissionsand/orfalsificationsthatyoumade,maydisqualify
you from consideration as a chaperone with the IDOC.
ProposedChaperone’sStatementofUnderstanding
I voluntarily agreed to provide this completed background questionnaire for the purpose of conducting a background check for consideration as a chaperone. I understand that the background
investigation questionnairemustbefullycompletedandnoinformationleft out.Iftheform ispartiallycompleted,Imaynot be considered as a chaperone.
ProposedChaperone’sStatementofCertification
I certifythatallof myanswersinthisquestionnairearetrueandcomplete.I understandthat anydiscrepancies, misstatements, omissions and/or falsifications will subject me to disqualification
from being eligible as a chaperone with IDOC.
ProposedChaperone’sPrintedNameProposedChaperone’sSignatureDate