Assumption Of Risk Form Short-Term Missions Volunteer (Page 2 of 2) in pdf

Background Check

PERMISSION FOR RELEASE OF INFORMATION

FROM CRIMINAL RECORDS- Missions

I hereby give my permission for the release to Barry Hardy, Church Administrator of First Baptist Church

of Madison, Mississippi, information from law enforcement files concerning any past history of sex offenses,

offenses against children with whom I may have been charged or convicted, and any criminal felony and

misdemeanor.

I understand that the information to be released will concern only charges and/or convictions of carnal

knowledge of a child less than 14 years of age, sexual battery, seduction of a child under the age of 18, touching

a child for lustful purposes, disseminating sexually oriented material to children, exploitation of children, carnal

knowledge of a stepchild, adopted child or a child of a cohabiting partner, or unnatural intercourse. Information

may be released on any criminal record I may have which does not relate to these particular crimes.

I understand that information will be released on any conviction, any pending charges, or any arrests if I have

been arrested two or more times.

I understand that First Baptist Church of Madison, Mississippi has the right to require this record check as a

condition of employment or my volunteering to work with children or participating in a mission trip.

I understand that if requested, I will be sent a copy of any information released from your files pursuant to this

permission form and I have the right to challenge the accuracy and completeness of this information.

I understand that this information will be used only for employment and/or volunteering purposes and will not

be re-disseminated to other persons or used for any other purpose.

Name: _______________________________________________

Physical Address: _______________________________

(Please print - full legal name)

_______________________________________

(City, State, Zip)

Social Security #: ____________________________________

Date of Birth: ________________________________________

Phone: __________________________________________

Email: ___________________________________________

Signature: ___________________________________________

Witness to Signature: ____________________________________________

Date: _________________________________

Assumption Of Risk Form Short-Term Missions Volunteer Page 2