Background Check Authorization Form

Please complete the form below to authorize a background check. Note, the information on this form will be used for a criminal history background check through the Department of State Police and/or Michigan Department of Corrections. If you have questions or need assistance, please contact Ben Mepham, Volunteer Manager, at bmepham@gildasclubgr.org.
  • Date Format: MM slash DD slash YYYY
  • Have you ever been convicted of a crime, do you have any pending charges, in the state of Michigan or elsewhere?
  • If applicable, please specify felony and gross misdemeanor crimes along with degree and conviction date.
  • Have you ever received a notice from a court or state agency stating that you have sexually abused, physically abused, neglected, abandoned, or exploited a child, juvenile, or adult?
  • Has a court ever written an order of protection or a restraining order lasting more than 30 days against you for abuse, neglect, financial exploitation, domestic violence, or abandonment of a vulnerable adult, juvenile, or child?
  • Do you currently, or have you within the past year, used controlled substances?
  • If you answered "yes" to the question,"Do you currently, or have you within the past year, used controlled substances?" Please explain:
  • Date Format: MM slash DD slash YYYY