Application For Children & Youth Workers And Background Information Consent Form (Page 3 of 4) in pdf

BACKGROUND INFORMATION CONSENT FORM

APPLICANT AUTHORIZATION AND RELEASE FORM

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in

this application to give you any information including opinions that they may have regarding my character and fitness for

children/youth work. In consideration of the receipt and evaluation of this application by the ______________________Church, I

hereby release any individual, church, youth organization, charity, employer, reference, or any other organization, including record

custodians, both collectively and individually, from any liability for damages of whatever kind or nature which may at any time result

to me, my heirs or family, on account of compliance or any attempts to comply, with this authorization. I waive any right that I may

have to inspect any information provided about me by any person or organization identified by me in this application.

Should my application be accepted, I agree to be bound by the bylaws and policies of __________________ Church and to

refrain from unscriptural conduct in the performance of my services on behalf of the church.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE

CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding

agreement that I have read and understand.

I also hereby authorize ______________________ Church and/or its agents to make an independent investigation of my

background, references, character, past employment, education, credit history, criminal or police records, including those

maintained by both public and private organizations and all public records for the purpose of confirming the information

contained on my application and/or obtaining other information which may be material to my qualifications for

employment/service now and, if applicable, during the tenure of my employment/service with ________________ Church.

These above mentioned background information checks may include, but are not limited to, employment and education

verifications, social security verification, driving record information, personal references, personal interviews and personal

credit history. I further understand that an acceptable credit report and/or background check will allow me to continue the

pre-employment/service process and that an unacceptable credit and/or background check may result in the discontinuation

of my pre-employment/service process. I understand if I am hired/serving prior to the completion of the background check

that an unacceptable background check will result in my termination.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any criminal background

search prepared on me upon written request within a reasonable time after the date of such search.

I further authorize any person, business entity or governmental agency who may have information relevant to the above to

disclose the same to ____________________ Church including but not limited to any courthouse, any public agency and all

law enforcement agencies and any and all credit bureaus regardless of whether such person, business entity or governmental

agency compiled the information itself or received it from other sources.

I release ______________________ Church and/or its agents and any persons, business entities and governmental agencies,

whether public or private, from any and all liability, claims and/or demands, of whatever kind, by me, my heirs and others

making such claim or demand on my behalf, for procuring, selling, providing, brokering and/or assisting with compilation or

preparation of the background information check hereby authorized.

Printed Name in Full

Applicant’s Signature

Date

Witness’s Signature

Date

Application For Children & Youth Workers And Background Information Consent Form Page 3