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Background Check Release Authorization

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
Introduction 
Stonebriar Community Church is committed to providing a safe and secure environment for all who enter our doors and participate in ministries and activities associated with our church. We therefore require that all who either serve or who are employed by Stonebriar undergo a criminal background check.  We know this can seem a bit daunting and/or intimidating, but it is a necessity in the world in which we live.  The information asked for is confidential, and we assure you that it is kept secure.  Thank you for your understanding and for taking the time to fill out this form.
Applicant, complete the following:
I. In connection with my volunteer application, I understand that a report or an investigative background check may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: workers’ compensation injuries, driving record, court record, education, credentials and references.
II. Medical and workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. Applicants are entitled to know if volunteering is denied because of information obtained by Stonebriar Community Church from a reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.
III. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original.  This release is valid for most federal, state and county agencies.
IV. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by Stonebriar Community Church or its agent, to furnish the information described in Section 1.
Please select the ministry or ministries with which you are currently serving or are interested in serving:
If 'other' is checked, please list:
The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records.  It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the requests for or release of any of the above mentioned information or reports.
*Last Name:
*First Name:
*Middle Name:
*Other name(s) you have used, ie maiden name or nickname (if none, type N/A):
*Date of Birth **Please check for accuracy before you submit**
The questions listed below are part of our screening process in order to help provide a safe and secure environment.  All information is held in strict confidence by SCC.  Answering “yes” to these questions may not necessarily preclude your involvement in a ministry.
*Have you ever been convicted of a criminal offense excluding minor traffic violations?
*Have you ever been convicted of any sexually related crimes?
*Have you ever been convicted of any abuse related crimes?
*Are there any circumstances involving your lifestyle and/or your background that would call into question your ability to work near children?
*Have you ever chosen not to renew or to discontinue employment or volunteer service, had your employment or volunteer service terminated, or been subject to disciplinary action, for reasons relating to allegations of sexual misconduct or abuse or neglect by you?
If you answered yes to any of the above, please explain below (or contact Kim Coleman 469-252-5372 to discuss):

The following states require sex and race to obtain information: AL, AR, FL, GA, IA, IN, MI, OR, TX, MI
*Sex:
*Race:
*Driver's License Number (If no driver's license, put N/A):
*State Issuing License (If no driver's license, put N/A):
*Name exactly as it appears on license, (if no driver's license, put N/A):
By my electronic signature provided below, I certify that I have read, understood, and agreed to comply with the above statements and agreements.
*Electronic Signature:

Please review your responses before you submit your background check form, especially dates, numbers, and email address.