DFPS 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 DFPS Background Check*

I grant permission to the CASA program to Request a Texas Abuse and Neglect background check through the Texas Department of Family and Protective Services on my behalf.

I am the person listed above and the information I provided is true and Correct. I grant permission to the CASA program to Request a Texas Abuse and Neglect background check through the Texas Department of Family and Protective Services on my behalf.

DFPS Security Agreement for CASA Employees/ Volunteers*

I agree to follow the DFPS Security Agreement

DFPS Security Agreement for CASA Employees/Volunteers

This agreement is for individuals who are not employees of the Texas Department of Family and Protective Services (DFPS),but who will be provided confidential information as part of a project, contract or agreement between DFPS and the organization the individual represents.

I understand and acknowledge that information made available to me by the Department of Family and Protective Services contains data that is considered confidential under law. I will use this information with discretion in performing my duties and responsibilities as a CASA Staff or volunteer and will disclose this information to other individuals only to the extent that is specifically authorized under the contract or agreement in place between my organization and DFPS. If at any time a question or problem arises with regard to the release of information, I will not release the information until I am so authorized. Under no circumstances will I access or release confidential information for any purpose other than in the performance of my duties and responsibilities as a CASA staff or volunteer as they relate to the contract or agreement with DFPS. I understand that if I use this information in an unauthorized manner, I may be subject to prosecution under one or more applicable statutes and will no longer be allowed access to the information provided to my organization.

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Please fill out the DFPS BackGround Check Release Form and Hit submit.

DFPS Background Check