CONSENT FOR CRIMINAL BACKGROUND HISTORY CHECK

AUTHORIZATION/WAIVER/INDEMNITY

Each staff member or volunteer who is to be screened must complete an authorization/waiver/indemnity form, giving approval for the Agency and the Volunteer Center to perform the criminal background search. REQUIRED WORDING FOR THE CONSENT FORM FOLLOWS:

I hereby give my permission in exchange for good and valuable consideration for the Round Rock Church of Christ to obtain information relating to my criminal history record through the Round Rock Church of Christ. The criminal history record, as received from the reporting agencies, may include arrest and conviction data, as well as plea bargains and deferred adjudications. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received.

I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify and defend the Round Rock Church of Christ and each of its officers, directors, employees, and agents harmless from, and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever, and any and all related attorney’s fees, court costs and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/staff member. 


The following information will be emailed to our office staff. Please rest assured that we will keep this information confidential and it will only be used for the purpose outlined above. Once complete we will delete this information from our records.

Name (Signature) *
Name (Signature)
Date *
Date
Date of Birth *
Date of Birth