CASA Background Check Release Form

Name*

First Middle Last

Other names or spellings used (married, maiden, alias, etc) First, Middle, Last

Address*

Street Address Address Line 2 City State ZIP Code

Address continued - County*

Primary Phone Number*

Alternative Phone

Date Of Birth*

Gender*

Male
Female

Social Security Number*

Race*

Asian
Black
White
Native Amercian
National Hawaii/Pacific Islander
Unable to Determine (or, non of the above)

Ethnicity*

Hispanic
Not Hispanic
Unable to Determine

List other places you have resided (For a minimum of the past 5 years)*

Email*

Consent for CASA of Grayson County Inc. Background Check*

I grant permission to the CASA of Grayson County Inc. to perform background checks as required by National and Texas CASA Standard 5(B) on my behalf.

I am the person listed above and the information I provided is true and Correct. I grant permission to the CASA of Grayson County Inc. to perform background checks as required by National and Texas CASA Standard 5(B) on my behalf.

I understand and acknowledge that CASA of Grayson County Inc. staff will not disclose this information to other individuals only to the extent that is specifically authorized.

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Please fill out and Submit the CASA of Grayson County Background Check Form.

CASA of Grayson County Inc. Background Check Form