Home » DFPS Background Check Release Form Please fill out the DFPS BackGround Check Release Form and Hit submit. DFPS Background Check Name* First Middle Last Other names or spellings used (married, maiden, alias, etc) First, Middle, LastAddress* 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 Address continued - County* Primary Phone Number*Alternative PhoneDate 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 AgreementDFPS 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.