Background Consent Form A

Full Legal Name *

First

Last

Have you ever used name(s) other than the one above? If yes, please list:

Date of Birth: *

Place of Birth (city, state, country) *

Race *

Social Security Number *

Driver's License Number: *

Driver's License State Issued *

any NOT child

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

If at current address less than two (2) years, please provide the previous address below:

Position applying/volunteering for: *

Is there any reason you should NOT work with or around children or youth?

Have you ever been the subject of a child abuse investigation? *

Have you ever been convicted of or pleaded guilty to a criminal offense? *

If yes, please provide details:

Please list two references:

Reference #1

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Years Known: *

Relationship: *

Reference #2

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Years Known: *

Relationship: *

I, hereby authorize Second Reformed Presbyterian Church and/or its agents to make an independent investigation of my background, references, character, past employment, education, criminal, or police records, including those maintained by both public and private organizations and all public records (the “Investigation”) for the purpose of confirming the information contained on my Application and/or obtaining other information, which in the sole discretion of Second Reformed Presbyterian Church may be material to my qualifications as a volunteer or for employment now, and if applicable, during the tenure of my volunteering or employment with Second Reformed Presbyterian Church. I understand, and authorize, a review of social media accounts if I am a minor. I understand that any false statements or implications made by me on this application or other required documentation shall be considered sufficient cause for denial of employment or volunteer opportunity, or discharge. (Note: criminal background checks will only be made for adult applicants).

I release and hold harmless Second Reformed Presbyterian Church, its employees, elders, deacons, and agents, and any person or entity that provides information pursuant to this authorization, from any and all liabilities, losses, claims, or lawsuits arising from or related to the Investigation.

Signature

Clear Signature