Host Family Background Check Form_2_2013 - Intrax

Host Family Background CheckThe U.S. Department of State has mandated that families hosting foreign exchange students undergo a backgroundcheck. All family members in the home who are 18 years of age or older must be checked. We ask for yourcooperation by completing this form and uploading it to your online host family application on My Intrax.My signature below authorizes Ayusa to conduct a background check with the personal information I have provided.This background check may include, but is not limited to, my driving history; a social security number verification;present and former addresses; and police records. I understand that this authorization and release shall be valid forsubsequent checks during my period of hosting with Ayusa.As a host family member with Ayusa, I hereby attest to the truthfulness of the representations I have made. If anystatement I have made is found to be false, my host family status with Ayusa may be revoked, regardless of the timeelapsed before discovery.I hereby release and agree to hold harmless from liability any person or organization that provides this information. Ialso agree to hold harmless Ayusa, and its officers, employees, and volunteers.Host Family AddressStreet Address:City: State: Zip:Host ParentLast Name: First Name: Full Middle:Birth Date: Gender: Male Female SSN: - -Signature:Date:Host ParentLast Name: First Name: Full Middle:Birth Date: Gender: Male Female SSN: - -Signature:Date:The information obtained is for internal use only and will be kept confidential to protect personal information. Federal regulations require Ayusato retain all records for three years after completion of the student program. After three years, all background check information will be shreddedto assure confidentiality.Rev. 02/13

Host Family Background CheckMy signature below authorizes Ayusa to conduct a background check with the personal information I have provided.This background check may include, but is not limited to, my driving history; a social security number verification;present and former addresses; and police records. I understand that this authorization and release shall be valid forsubsequent checks during my period of hosting with Ayusa.As a host family member with Ayusa, I hereby attest to the truthfulness of the representations I have made. If anystatement I have made is found to be false, my host family status with Ayusa may be revoked, regardless of the timeelapsed before discovery.I hereby release and agree to hold harmless from liability any person or organization that provides this information. Ialso agree to hold harmless Ayusa, and its officers, employees, and volunteers.Host Family AddressStreet Address:City: State: Zip:Other Family Member (age 18 or over)Last Name: First Name: Full Middle:Birth Date: Gender: Male Female SSN: - -Signature:Date:Other Family Member (age 18 or over)Last Name: First Name: Full Middle:Birth Date: Gender: Male Female SSN: - -Signature:Date:Other Family Member (age 18 or over)Last Name: First Name: Full Middle:Birth Date: Gender: Male Female SSN: - -Signature:Date:Office Use OnlyRM RD CRPlease upload your completed form to your online hostfamily application on My Intrax.Page 2 of 2 Rev. 02/13