Criminal History Background Report

Ronald McDonald House of Cleveland (“RMH”) conducts a criminal history background check on all individuals (18 years old or older) who will be staying at RMH.  In selecting family members and visitors for temporary residence, RMH screens individual’s suitability for temporary residence among other families.  A criminal conviction record which reveals behavior that may adversely affect another individual’s (e.g., other temporary residents, guests, staff, volunteers) health, safety, welfare and ability to peacefully enjoy the RMH facility shall result in your application for temporary residence being denied.  This information will include but not be limited to allegations and convictions for crimes committed upon minors and will be gathered from any law-enforcement agency of this State or Federal government, to the extent permitted by State and Federal law.  For example, and without limitation, convictions of violent crimes, domestic violence, child abuse, sex offenses, illegal drug activity, burglary, and/or identity theft will result in rejection of your application.

This form includes a Criminal History Background Report Authorization form for you to review and sign.  Each family member or overnight visitor (18 years old or older) who intends to establish temporary residence must separately fill out this form and the Criminal History Background Report Authorization form.  Once we receive the completed form, RMH will have an independent third party conduct a criminal history background check.

RMH will attempt to obtain and use a criminal history background “consumer report” from a “consumer reporting agency” when considering your request for temporary residence while your child (or family relation) is receiving medical treatment at a Cleveland medical center.  These quoted terms are defined in the Fair Credit Reporting Act (“FCRA”), a law which RMH deems to apply to you. As an applicant for temporary residence at our facility, RMH is considering you to be a “consumer” with rights under the FCRA. 

A “consumer reporting agency” is a person or business that, for monetary fees, dues or on a cooperative nonprofit basis, regularly assembles or evaluates consumer credit information or other information on consumers for the purpose of furnishing “consumer reports” to others, such as RMH.  A “consumer report” that will be used by RMH is any written, oral or other communication of any information by a “consumer reporting agency” bearing oncharacter, general reputation, personal characteristics, motor vehicle record, or mode of living that is used or collected for the purpose of serving as a factor in establishing the consumer’s eligibility to stay at RMH.   A “consumer report” also may include, without limitation, information about your employment history, educational background, or your criminal history background.

Please understand that RMH solely will obtain a criminal history background report to assist it in determining whether to grant you temporary residence.  RMH is not obtaining a “consumer report” for any other information and will NOT be conducting a credit check.

If RMH considers any information in the criminal history background report when making a temporary residence decision that directly and adversely affects you, you will be provided with a copy of that report.  You also may contact the Federal Trade Commission about your rights under the FCRA as a “consumer” with regard to “consumer reports” and “consumer reporting agencies.” FCRA Summary of Rights

To assist you in truthfully and completely answering the form, please be advised your application will be in jeopardy if you have been convicted of any of the criminal offenses (whether or not the offense may have been labeled in another way in your state or country of residence) listed on the downloadable form. This list is not all-inclusive.

RMH, in its sole discretion, will determine whether your criminal record may threaten an individual’s health, safety, welfare, and ability to peacefully enjoy the RMH facility and, therefore, result in your request for temporary residence being denied.  You are required to promptly notify RMH’s Family Services Manager or Assistant Manager if your answer to the above-referenced questions needs to be updated.

RMH will in addition make an overall decision whether the rest of your family will be eligible to stay based on their individual checks.

I certify that all of the above-provided information is accurate, complete and can be verified.  I agree and understand that any falsification, misrepresentation, or omission may disqualify me from seeking temporary residence at RMH; or if temporary residence already has been granted, then it will subject me to immediate removal from RMH whenever the falsification, misrepresentation or omission is discovered.  I also understand that while RMH will obtain criminal history background information on potential temporary residents, it cannot and does not guarantee the personal safety of any temporary resident, guest, visitor, or staff member.

Authorization

By signing below, I knowingly and voluntarily authorize the Ronald McDonald House of Cleveland (“RMH”) to obtain a criminal history background report from a “consumer reporting agency” and to consider that report when determining whether to grant me temporary residence at RMH.  I understand I have rights under the FCRA, including the rights discussed in the FCRA Summary of Rights, which has been provided to me along with this Authorization form.  This Authorization shall remain on file and shall serve as ongoing authorization for RMH to obtain criminal history background reports on me when I apply for temporary residence at RMH.  I also acknowledge receiving a written Summary of Rights under the FCRA along with this Criminal History Background Report Authorization form.

Fill out my online form.

Or you may download and print the form.