CONSENT FOR BACKGROUND CHECK AUTHORIZATION/WAIVER/INDEMNITY

I herby give my full consent and permission to    

Forks Township Youth Sports Organization

in order to obtain information relating to my criminal history and any other applicable records through National Center for Safety Initiatives LLC and their agents. The records as received by the reporting agencies may include but not limited to arrest, conviction, social security verification and/or driving records as well as plea bargains, deferred adjudications, and delinquent conduct committed as a juvenile. I understand that this information will be used in part to determine my eligibility for a volunteer or staff/board position within this organization. I also understand that as long as I remain in such capacity here, the above mentioned record checks may be repeated at any time. I understand that I will have an opportunity to review the records as received by

Forks Township Youth Sports Organization

and a procedure is available for clarification, if I dispute the records that have been received. I also understand that the records received could contain information presumed expunged.

I, the undersigned, do for myself, my hires, executors and administrators, hereby remise, release, and forever discharge and agree to indemnify National Center for Safety Initiatives LLC and   

Forks Township Youth Sports Organization

, each of their officers, directors, employees, volunteers and agents and hold them harmless from and against any and all causes and actions, including but not limited to: suits, liabilities, costs, debts, and sums of money, claims, and demands whatsoever (including claims for negligence, gross negligence, and/or strict liability) 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 serve.

I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERSTAND THE CONSENT FOR THE ABOVE RECORD CHECKS AND THAT I ACCEPT AND SIGN THIS FORM VOULNTARILY.

Applicant’s Legal Name Including First, Middle, Last Name and Suffix:

Applicant’s Aliases / Maiden Names: Social Security Number: Date of Birth:

Current Address:

City: State: Zip:

Day Time Telephone Number Shirt Size (S-M-L-XL-XXL) Drivers License Number & State

Male or Female SIZE:

Signature: & NAME OF SPORT Date:

$8.00 Check is required for each background check being returned.

Returned Background Form and Check to your commissioner.

Make Check payable to FTSYO