Authorization for Release of Information
__________________Confidential__________________
Applicant Information (Please print legibly.)
Name: _______________________ Date of Birth: (Mo/Day/Year) _____/____/ ____ Place of Birth: City: ______________________County:_____________ State:_____________ Social Security Number: _____-____-_____ Current Address: _________________________________________ Telephone number:(____)_________ Driver's License Number: ________________ Issuing State: ___________ List previous addresses within the past five years (attach a separate sheet if necessary). Address: _________________________________________ Address: _________________________________________ Address: _________________________________________ Release to do Reference Checks and Criminal Records Check I authorize my references, present and past employers, and churches listed in this application, to give this church any information, including opinions, they may have regarding my character and fitness for child care and youth work, or other volunteer ministry or employment. This release and authorization acknowledges that this church may now, or at any time while I am employed or work as a volunteer, obtain and use a "consumer report" about me, which may include verification of my education, previous employment/work history, driving record, and criminal record that may be in the files of the federal, state, or local criminal justice agency in any state. A photocopy or fax of this Authorization and Consent for Release of Information shall be valid as the original. The results of this verification process will be used to determine employment or volunteer eligibility. All results will be kept CONFIDENTIAL. The information obtained will not be provided to any parties other than to designated church personnel. I authorize a criminal background check organization, and any of their agents or designated company personnel, or a police department to release to this church any information that pertains to any record of convictions in its file or in any criminal file maintained on me, whether local, state, or national, and to disclose orally and in writing the results of this verification process to authorized representatives. I do hereby agree to forever release and discharge this church and their associates, and all such individuals, employers, churches, and organizations, to the full extent permitted by law, from any claims, damages, losses, liabilities, costs and expenses, or any other charge or complaint arising from the retrieving and reporting of information. In the event that information from the consumer report is utilized in whole or in part in making an adverse decision with regard to my application, before making the adverse decision, the church will provide me with a copy of the report and a description in writing of my rights under the law. I hereby authorize ________________________________ Name Of Church to obtain a consumer report on me. Applicant's Signature _____________________________ Date _____________ Applicant's Name Typed or Printed: ____________________ Last reviewed by legal counsel on _____________________________    Working in Team MinistryHelp your teams work together for maximum impact.  Grow and Care for VolunteersCaring for volunteers helps them care for children. Top 10 Volunteer Needs What each volunteer needs to stay with the ministry.
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