For criminal history review



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ProCare Hospice of Nevada

VOLUNTEER CONSENT AND RELEASE FORM

FOR CRIMINAL HISTORY REVIEW

1. I have never been convicted of murder, voluntary manslaughter or mayhem.
2. I have never been convicted of assault with intent to kill or to commit sexual assault or mayhem.
3. I have never been convicted of sexual assault, statutory sexual seduction, incest, lewdness or indecent exposure or any other sexually related crime that is punished as a felony (including felony prostitution.)
4. I have never been convicted of prostitution, solicitation, lewdness or indecent exposure, or any other sexually related crime that is punished as a misdemeanor, within the immediately preceding 7 years.
5. I have never been convicted of a crime involving domestic violence that is punished as a felony.
6. I have never been convicted of a crime involving domestic violence that is punished as a misdemeanor, within the immediately preceding 7 years.
7. I have never been convicted of abuse or neglect of a child or contributory delinquency.
8. Within the past seven years, I have not been convicted of any federal or state law regulating the possession, distribution or use of any controlled substance or any dangerous drug as defined in chapter 454 or NRS within the immediately preceding 7 years.
9. I have never been convicted of abuse, neglect, exploitation or isolation of older persons or vulnerable persons, or any provision of NRS 200.5091 to 200.50995, inclusive, or a law of any other state or other jurisdiction that prohibits the same or similar conduct.
10. Within the past seven years, I have not been convicted of any provision of law relating to the State Plan for Medicaid or a law of any other state or other jurisdiction that prohibits the same or similar conduct.
11. I have never been convicted of a violation of any provision of NRS 422.450 to 422.590, inclusive, statutory provisions relating to Nevada’s State Plan for Medicaid.
12. Within the past seven years, I have not been convicted of a criminal offense under the laws governing Medicaid or Medicare.
13. Within the past seven years, I have not been convicted of any offense involving fraud, theft, embezzlement, burglary, robbery, fraudulent conversion or misappropriation of property.
14. I have never been convicted of any felony involving the use or threatened use of force or violence against the victim or the use of a firearm or other deadly weapon.
15. I have not been convicted of an attempt or conspiracy to commit any of the offenses listed in numbers 1 through 14 within the immediately preceding 7 years.
I affirm that the statements 1 – 15 above are true and correct.

Full Legal Name: ____________________________________________________________________________


Maiden Name (if applicable): _______________________________________________________________
Signature: _____________________________________________ Date: ____________________________


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