Washington State Background Check Agreement

indicates a required answer

Every on-site adult with a permanent name tag must pass a Washington State Background Check each year. Please complete this form to consent to an annual Washington State Background Check.

1.	Full Name: First, Middle, and Last

2.	Alias / Maiden Name

3.	Birthdate (mm/dd/yyyy)

4. *

I understand that, because I will be working with and near children, permission for a Washington State Patrol background check is required for all who will work a regular job on campus. Here is my information so that the background check may be conducted by a Heritage Board member. This information will be kept safe and secure. I will be notified of the response of the search if there is any concern. If I have concerns about this, I understand it is my responsibility to contact the safety coordinator at [email protected].

(1 required)

I understand