Background Check Form - A Lighthouse For Kids

Basic Information

*Required fields are indicated with a red asterisk. Please fill in all required fields. Failure to fill in all required fields will result in your form not being submitted.

Your Name*

First Middle Last

Maiden Name

If Applicable

Your SSN*

Your Phone*

Your Email*

Driver's License Upload

Accepted file types: jpg, png, pdf, Max. file size: 15 MB.

Allowed File Types are jpg, png, pdf
Max File Size: 15MB
If you are having issues uploading the file here, submit a copy of your drivers license to staffcoordinator@alighthouseforkids.com

If you are CPR certified please upload documentation here.

Accepted file types: jpg, png, pdf, Max. file size: 15 MB.

Allowed File Types are jpg, png, pdf
Max File Size: 15MB
If you are having issues uploading the file here, submit a copy of your drivers license to staffcoordinator@alighthouseforkids.com

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Date of Birth*

Other States Lived in:*

If you have not lived in any other state, type NONE.
Click the (+) for additional lines.

Other Alias Names used:*

If you have never used another name, type NONE.
Click the (+) for additional lines.

Please give your last 5 years of employment to include any time as a fulltime student or unemployed*

Name/City/State	Phone	From / To	Position Held

Example:
ABC Day Care / Beaumont / TX -- 325-642-1234 -- Jan. 2016 to present -- childcare worker
Sherman High School / Sherman / TX -- 903-642-1234 -- Aug. 2012 / May 2016 -- Full time student
Click the (+) for additional lines

Please add three references that are not relatives.*

Their Name	Their Phone	How you know them	How long you have known them

Such as Friends, Pastors, or Supervisors

Do you have any prior criminal arrests and/or convictions to include any traffic citation for child safety issues*

Yes
No

If so, please give the date(s) of the offenses, nature of the offenses, and any other pertinent information.*

Authorization Section

By agreeing below, I do hereby give permission to A Lighthouse For Kids to run a background check for the purpose of working on the government contract for the military. I understand that this is a requirement by the military to be able to work on the contract performing childcare. I understand that everyone is required to have this done BEFORE they can work.*

Agree
Disagree

Name*

First Middle Initial Last

I affirm that the person filling out this form is the person listed above.*

Agree
Disagree

Comments

This field is for validation purposes and should be left unchanged.

Background Check Authorization Form

Fill out the form below!

Basic Information

Authorization Section