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FORM #140 (AS)

Revised 2/1/2005

CRIMINAL BACKGROUND RECORDS WAIVER OF LIABILITY, DISCLOSURE,

AUTHORIZATION AND RELEASE

CANDIDATES APPLYING OR VOLUNTEERING FOR, OR EXISTING EMPLOYEES, WORKING IN A POSITION

REQUIRING A CRIMINAL BACKGROUND CHECK, COMPLETE THE FOLLOWING:

As part of the risk management process and pursuant to its policies, Johnson County Park and Recreation

District (the “District”) will perform checks of criminal history records on existing employees, individuals seeking

employment with the District, including regular and seasonal new hires and volunteers, who will work with

children, individuals with disabilities, and/or persons with frail and fragile physical circumstances or preconditions,

or other circumstances as the District deems necessary. Such individuals will be required to maintain satisfactory

criminal history records as a condition of employment.

In addition, the District may periodically perform

background checks randomly on employees who have been previously checked and who continue to be involved

in a position with the District whereby District policy would require such background checks of such individual.

In consideration of my employment or volunteer eligibility (or continued employment or volunteer eligibility if I am

currently an employee or volunteer) with the Johnson County Park and Recreation District, (Please Print)

I,_____________________________, hereby authorize and give consent for the District to obtain information

pertaining to possible criminal history on myself. This includes the following:

•

Criminal Background Records/Information

•

Sex Offender Registry Information

•

Addresses and Social Security Number Verification

I hereby release from liability and promise to hold harmless under any and all possible claims or causes of action

(i) any and all persons or entities who shall furnish such information to the District, its officers, agents or

employees, and (ii) the District, its officers, agents or employees for any statements, acts or omissions in the

course of obtaining said information. Furthermore, I understand that this release is signed, free from duress, and

with the full knowledge and understanding that any information obtained will be used in assessing my relative

fitness for employment or volunteer eligibility with the District and that such information will be held in confidence

in accordance with the organization’s guidelines.

These records being checked are covered by the Fair Credit Reporting Act. The Fair Credit Reporting Act gives

me specific rights in dealing with agencies that provide these reports to the District. Enclosed with this Release,

Disclosure and Authorization is “A Summary of Your Rights Under The Fair Credit Reporting Act”, including

appeal procedures. Before making any adverse employment action which is based on the information received

from a criminal background check, the District will notify me in writing and will provide me with a copy of the report

and “A Summary of Your Rights Under The Fair Credit Reporting Act”.

(Please Print)

Full Name:

Last

First

Middle

Any Other Name Used:

Social Security Number:

Date of Birth

Current Address:

Street

City

State

Zip Code

Drivers License Number:

State:

District Work Location:

District Position:

Supervisor’s Name:

By my signature below, I hereby acknowledge the information outlined above and I also authorize Johnson

County Park and Recreation District to obtain such records.

(If a minor (under age 18), signature must be accompanied by parent’s or legal guardian’s signature.)

Signature:

Date Signed:

__________________________________________________________________________________________

Parent’s or Legal Guardian’s Signature (if required):

Date Signed:

PLEASE SEND COMPLETED FORM TO HR DEPT, DISTRICT ADMINISTRATION BUILDING,

7900 RENNER ROAD, SHAWNEE MISSION, KANSAS 66219, 913-438-7275, fax: 913-894-3395

Form 140 (As) - Criminal Background Records Waiver Of Liability, Disclosure, Authorization And Release

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