Applicant Identification
and Release Form
Early Childhood Education Program
Regarding investigation of founded child or dependent adult abuse, criminal history or driving record identification: (Please Print)
Health Sciences Program: Early Childhood Education
Last Name: First Name: Middle:
Alias, Maiden, Previous Married Name (Please list every previous name):
Address: City: State: Zip:
Date of Birth (mm/dd/yy): / / Social Security Number: - -
Race: Sex: M F
Driver’s License Number: State Issuing License:
Do you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime in this state or any other state?
No Yes
If yes, please explain the nature of the incident and date of occurrence:
AUTHORIZATION AND RELEASE
The undersigned acknowledges:
1. I have executed this document in conjunction with admission into a health sciences program at Indian Hills Community College
District. (Hereinafter referred to as “IHCC”).
2. I hereby authorize IHCC access to any criminal history record produced by federal, state or local law agencies pertaining to me.
3. I agree to release IHCC and any other person, company or other entity from any and all causes of action that otherwise might arise
from supplying clinical agencies with information they may request pursuant to this release.
4. I understand that any false answers or statements or misrepresentations by omission made by me on this form or any related
document will be sucient cause for rejection of my application or for my immediate discharge should such falsifications or
misrepresentation be discovered after the program begins.
5. I understand and agree that if I am rejected for participation in a clinical experience by an aliating agency or if I refuse to submit
to the registry checks that are required by an aliating agency, I will be unable to complete my program of study in the specified
program.
6. I understand that during my educational program at IHCC, it is my responsibility to report any criminal, child abuse and adult
abuse charges pending against my record. I further authorize IHCC to conduct background checks on my record at any time
during my educational program as needed.
Signature:
Date:
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