Appendix G: Release of Information Form
RELEASE OF INFORMATION FORM
Full Name: __________________________________________________________________
I authorize Moberly Area Community College to request and obtain a copy of my criminal background as provided in Section 610.120 RSMo and make an inquiry to the Department of Social Services regarding the “Employee Disqualification List” as provided in Section 660.315. I also authorize Moberly Area Community College to request and obtain a copy of my drug screen results, a Division of Family Services background check regarding child abuse or neglect, a background check with the Office of Inspector General, and a Caregiver screening check regarding abuse to mental health clients. I also realize additional background screenings may be requested by the clinical sites affiliated with Moberly Area Community College. I also realize I must provide a criminal background check for each state I have lived in within the past 10 years.
I further authorize Moberly Area Community College to provide the necessary documentation of all of the above stated data and self-reported information to individual clinical affiliates. This information is to verify my eligibility to participate in the clinical experience.
Student Printed Name: _______________________________________________________
Student Signature: ___________________________________________________________
Date: _____________________________________________________________________
Witness: ___________________________________________________________________
Date: _____________________________________________________________________