INDIVIDUAL VERIFICATION OF BACKGROUND CHECK
I, ____________________________, wish to be part of a University of Dayton
(“University”) program that involves minors. This program will involve overnight stays, and I
would like to be an authorized adult who is involved in that overnight-stay component of the
program.
I understand that, under its Minors on Campus and Working with Children Policy and
Background Check Policy, the University requires adults who are involved in the overnight-stay
component of a minors program on campus to successfully complete, annually, a background
check. The University’s background checks search county criminal records, federal criminal
records, the national criminal database, and the sex offender database, for information regarding,
among other things, felonies, sexual offenses, drug offenses and incidents involving violence.
I have recently undergone a comparable background check, on ___________, with
“successful” results (that is, no offenses in the categories mentioned above), because of my work
or volunteering through (describe circumstances/program through which background check
performed): ___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I have attached documentation showing that this background check was performed with
successful results, consistent with my statements above.
I understand that, if I falsify any information in this form or the attached documentation,
such falsification may result in the loss of the privilege of being involved in University programs
where minors are expected to be present, and such falsification may be considered a violation of
other University policy and therefore result in other, additional consequences.
Signature: ________________________
Printed name: _____________________
Title: ____________________________
Date: ____________________________
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