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AUTHORIZATION AND REQUEST FOR CRIMINAL RECORDS CHECK – on BOTH PARENTS 

(in order to ensure safety for all of our students when parents serve at school) 

I, (name of parent)___________________________________________, hereby authorize The Daniel Academy from time to time, as deemed appropriate, to request any law enforcement agency, or any other agency chosen by The Daniel Academy specifically for conducting this search to release information regarding any record of charges or convictions contained in its files, or any criminal file maintained on me, whether local, state, or national, and including but not limited to accusations and convictions or crimes committed against minors, to the fullest extent permitted by local, state and federal law. I do release said law enforcement agencies and any other entities from all liability that may result from any such disclosure made in response to this request.

Signature of Applicant (Parent) Date 

Print applicant’s (parent) full name: ________________________________________________ 

Print all other names that have been used by applicant (if any):_____________________

_______________________________________________________________________ 

Social Security number (required)____________________________ 

Date of birth: ______________________________________ 

Place of birth:______________________________________ 

Current Address Street/Apt ____________________________________ 

City, State, Zip Code _____________________________________ 

Most recent previous address if outside the Kansas City Metro Area 

Street/Apt. _________________________________________________ 

City, State, ZipCode ____________________________________________ 

Driver’s license number: __________________________________ 

State issuing license: _____________________________ 

License expiration date:_________________________ 

Daytime Phone:_____________________________________________ 

Email: ___________________________________________________