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RIVERPLACE COUNSELING CENTERS <br />POLICY REGARDING CONVICTED SEX OFFENDERS <br />It is the policy of Riverplace, to provide its clients, staff, and local community with a <br />safe environment free from the risk of criminal sexual conduct. Therefore, it is the <br />policy of Riverplace, that no applicants be accepted into the Riverplace treatment <br />program who have been convicted of criminal sexual conduct and are required to <br />register as predatory offenders under Minnesota Statutes, Section 243.166. This <br />includes predatory offenders with a risk level of I, II, or III on the risk assessment scale <br />set out in Minnesota Statutes, Section 244.052. By signing this form, applicants certify <br />that they are not required to register as predatory offenders under Minnesota law nor have <br />they been convicted of or have legal charges pending related to possible conviction as a <br />sexual offense. This information shall be kept confidential and shall be used for no <br />other purpose than for determining admission for treatment. Applicants may refuse to <br />provide this information. However, an applicant's refusal to disclose this information <br />shall result in automatic denial of admission into the Riverplace chemical dependency <br />care program. <br />I hereby certify that I have read, and fully understand the convicted sex offender <br />policy, and further certify that I am not required to register as a predatory offender <br />under Minnesota law due to a sex crime conviction. <br />Client Signature; <br />Witness Signature: <br />Date: <br />Date: <br />