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Background Check
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Temporary Lodging Inquiry Release
In order to ensure the safety of all guests at the Ronald McDonald House, RMHC of Southern Arizona conducts a criminal background check on prospective guests age 18 and older.
By completing this form, you agree to allow RMHC of Southern Arizona to conduct a criminal background check. Please note that, even though the legal name for this report is a “Consumer Report”, this is NOT a credit check. Please also note that everyone in your party age 18 and older who will be staying at the Ronald McDonald House must also sign a release. Your name and date of birth below represent an electronic signature.
If you have question or concerns, we invite you to call us at 520-326-0060 and ask for the House Manager on duty.
Petición de consulta de alojamiento temporal
Con el fin de garantizar la seguridad de todos los huéspedes en la Casa de Ronald McDonald, RMHC del Sur de Arizona realiza una verificación de antecedentes penales de los posibles huéspedes mayores de 18 años.
Al completar este formulario, usted acepta que RMHC del Sur de Arizona realice una verificación de antecedentes penales. Tenga en cuenta que, aunque el nombre legal de este informe es “Informe del consumidor”, NO es una verificación de crédito. Tenga en cuenta también que todos los miembros de su grupo de 18 años o más que se alojarán en la Casa de Ronald McDonald también deben firmar una exención. Se le proporcionará un enlace una vez que lo complete, y el formulario está disponible en la página web
Ronald McDonald House
. Su nombre y fecha de nacimiento a continuación representan una firma electrónica.
Si tiene alguna pregunta o inquietud, lo invitamos a que nos llame al 520-326-0060 y pregunte por el Gerente de la Casa de turno.
Name
*
Legal Name
In order to properly process your application, please make sure that your name matches the name on your driver’s license (or other government issued identification). If your name does not match your date of birth, your application could be delayed.
First
Middle
Last
Suffix
Name
*
Firma electrónica: ingrese su nombre legal y fecha de nacimiento. Para procesar correctamente su solicitud, asegúrese de que su nombre coincida con el nombre de su licencia de conducir (u otra identificación emitida por el gobierno). Si su nombre no coincide con su fecha de nacimiento, su solicitud podría demorarse.
Primer
Segundo
Apellido
Sufijo
Patient Name
*
If patient has not yet been born, please provide the mother’s first and last name.
Nombre de paciente
*
Si el paciente no ha nacido, por favor de proporcionar el primer nombre y el apellido del la mamá.
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Country
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Address
*
Address
Dirección
Ciudad
Estado
Codigo postal
País
País
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Phone
Optional
– Providing your phone number allows us to contact you with any questions or requests for clarification.
Numero de teléfono
Opcional – Al proporcionar su numero telefonico nos permite contactarlo en caso de una pregunta o clarificacion.
Email
*
If you provide your email address, we can send you a copy of your background check results.
Email
*
Si proprociona su correo electrónico, podemos mandarle una copia de su resultados de la verificación de antecedentes.
Temporary Lodging Inquiry Release
*
Temporary Lodging Inquiry Release
In conjunction with my request to stay temporarily as a guest at the Ronald McDonald House® in Tucson, Arizona , I understand that Ronald McDonald House Charities® of Southern Arizona (RMHCSA) intends to hire SELECTiON.COM® to conduct a criminal background check and/or, if applicable, to obtain Consumer Reports and / or Investigative Consumer Reports (hereinafter called Reports) about me as defined in the federal Fair Credit Reporting Act (FCRA). These Reports may include information concerning my criminal record, if any.
I understand that RMHCSA may rely on any or all of the above referenced information in determining whether to allow me to stay temporarily at the Ronald McDonald House as a guest. If RMHCSA contemplates making an adverse decision that will affect me based, in whole or in part, upon a Report obtained from SELECTiON.COM®, RMHCSA will provide me with a copy of the Report and a written summary of my Consumer Rights under the FCRA, if applicable, before RMHCSA finalizes that decision.
I have read the above disclosure, and I hereby authorize RMHCSA, SELECTiON.COM® or its / their authorized agents to obtain the above referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above referenced knowledge or information they have concerning me. If I am permitted to stay temporarily at the Ronald McDonald House, this authorization shall remain on file and shall serve as an ongoing authorization for RMHCSA to obtain other Reports about me from SELECTiON.COM® at any time during my stay at the Ronald McDonald House. A photocopy or facsimile of this authorization shall be as valid as the original.
I agree
Temporary Lodging Inquiry Release
*
Ley de Informe Justo de Crédito – Divulgación de Verificación de Antecedentes
Junto con mi solicitud de permanecer temporalmente como invitado en Ronald McDonald House® en Tucson, Arizona, entiendo que Ronald McDonald House Charities® del sur de Arizona (RMHCSA) tiene la intención de contratar a SELECTiON.COM® para realizar una verificación de antecedentes penales y / o, si corresponde, para obtener Informes del Consumidor y / o Informes del Consumidor Investigativos (en adelante, Informes) acerca de mí, según se define en la Ley Federal de Informes de Crédito Justo (FCRA). Estos informes pueden incluir información sobre mis antecedentes penales, si corresponde.
Entiendo que RMHCSA puede depender de cualquiera o toda la información mencionada anteriormente para determinar si me permite quedarme temporalmente en la Casa de Ronald McDonald como invitado. Si RMHCSA contempla tomar una decisión adversa que me afectará, en su totalidad o en parte, en un Informe obtenido de SELECTiON.COM®, RMHCSA me proporcionará una copia del Informe y un resumen escrito de mis Derechos del consumidor según la FCRA , si corresponde, antes de que RMHCSA finalice esa decisión.
He leído la divulgación anterior, y por la presente autorizo a RMHCSA, SELECTiON.COM® o sus agentes autorizados a obtener la información antes mencionada sobre mí. También autorizo a todas las agencias, oficinas, empleadores, organizaciones de servicios de información e individuos a que proporcionen cualquiera de los conocimientos o información que tienen sobre mí, a los que se hace referencia anteriormente. Si se me permite permanecer temporalmente en la Casa Ronald McDonald, esta autorización permanecerá en el archivo y servirá como una autorización continua para que RMHCSA obtenga otros Informes sobre mí de SELECTiON.COM® en cualquier momento durante mi estancia en la Casa de Ronald McDonald . Una fotocopia o fax de esta autorización será tan válida como el original.
Estoy de acuerdo
Electronic Signature
*
Please provide your legal name and date of birth as your electronic signature.
Electronic Signature
*
Por favor propocione su nombre legal y fecha de nacimiento como su firma electrónica
Date of Birth
*
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Fecha de nacimiento
*
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Mes
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Año
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