Background Check Authorization, Waiver and Release of All Claims

Church: ______

BACKGROUND CHECK AUTHORIZATION, WAIVER AND RELEASE OF ALL CLAIMS

PLEASE READ THIS FORM CAREFULLY

BY COMPLETING THIS FORM, YOU WILL BE AGREEING TO ALLOW THE CHURCH TO CONDUCT A BACKGROUND CHECK OF YOUR PERSONAL BACKGROUND IN EACH OF THE FOLLOWING AREAS [SO NOTED WITH A “Y” BELOW]:

SEXUAL OFFENDER REGISTRY [Y,N]_____; CRIMINALHISTORY; [Y,N]_____; SOCIAL SECURITY # TRACE [Y,N]_____;

DRIVER LICENSE VERIFICATIONDRIVING HISTORY [Y,N]_____; CREDIT [Y,N]_____; EDUCATION [Y,N]_____.

ADDITIONALLY, YOU AGREE TO WAIVE AND RELEASE ALL CLAIMS FOR DAMAGES YOUMIGHT SUSTAIN ARISING OUT OF THESE BACKGROUND CHECKS AND REVIEW THEREOF.

Please initial each of the following:

______I understand that completion of a background check is a condition of my service to the church.

______I understand that the church reserves the right to conduct a Sexual Offender Registry check on any person serving the

church in any capacity — or any other person who demonstrates certain behavior while with or near children or youth

who are in the care of the church — with or without written approval or advanced notification.

______I authorize the church to conduct a background check on my personal history in the areas so designated above with a “Y”.

______I understand that the church may, at its sole discretion, perform additional follow-up background checks in the areas so

authorized above.

______I agree to waive and relinquish all claims I may have against the church and its officers, agents and employees, as a result

of participating in the background check.

______I do hereby fully release and discharge the church, its respective officers, agents and employees from all claims from

damages which I may have or which may accrue to me on account of the results of any aspect of the background check.

______I attest to the accuracy of all of the information I provided on this form.

______I have read and fully understand this Authorization, Waiver and Release of All Claims.

SIGNED: ______DATE: ______

Clearly print your full legal name, including designation (Jr., Sr., III, etc.). Married women, please include maiden name in parentheses. For example: Pamela Jane (Thompson) Henderson:

______

Full Address:

______

Social Security Number: ______Date of Birth: ______

Driver License Number: ______D.L. State: ______

City and State of Birth: ______Mother’s Maiden Name:______

Print complete name(s) by which you are or were known that are different than your current legal name (including nicknames):

______

If you have changed residence in the past 5 years, list your complete previous address(s) for the past 5 years:

______