Health Programs – Background Check Authorization Listen Name * Required First Middle Last Alias, maiden, previous married name (Please list every previous name - most recent first) Address * Required Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birth Date * Required MM slash DD slash YYYY Social Security Number * Required Gender * Required Female Male Phone * RequiredDo you have a record of founded child or dependent adult abuse or have you ever been convicted of a crime in Iowa or any other state? * Required No Yes please explain the nature of the incident and date of occurrence. * RequiredAuthorization and ReleaseThe undersigned acknowledges: 1. I have executed this document in conjunction with admission into a health program at Northwest Iowa Community College. (Hereinafter referred to as “NCC”.) 2. I hereby authorize NCC access to any criminal history record produced by federal, state, or local law agencies pertaining to me. 3. I agree to release NCC 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 sufficient cause for rejection of my application or for my immediate discharge should such falsifications or misrepresentation be discovered after my nurse aide program begins. 5. I understand and agree that if I am rejected for participation in a clinical experience by an affiliating agency or if I refuse to submit to the registry checks that are required by an affiliating agency, I will be unable to complete my program of study in the health program I am enrolled in. 6. I understand that during the course of my education at NCC it is my responsibility to report any criminal, child abuse, and adult abuse charges pending against me. Applicant Initials * Required By placing your initials here, you acknowledge that you understand your rights and responsibilities.CAPTCHA
