Background Check Combinedpdf
Background Check Combinedpdf
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  1. First Class Christian Homeschool Co-opChild Youth Worker Agreement***********Confidential***********Date: _______/_______/_______Name: ____________________________________________________________________________ Birthdate: __________________________Identity must be confirmed with a state driver’s license or other photographic identification.Address:____________________________________________________________________________ Phone: (_______)____________________Have you: (Please circle appropriate response)1. Been convicted of any crime or is there a criminal charge pending against you? Yes No2. Been released from prison in the last seven years? Yes No3. Had your name placedon a registry of child abuse in this or any state? Yes No4. Been found to have sexually abused or exploited or physically abused anychild or adult:a. in any court action or proceedings? Yes Nob. by a professional disciplinary board or the Department of Licensing?YesNo(If yes, the state, the date, place and nature of the proceedings.) 5. Been denied a license to care for children or adults? YesNo6. Had a license to care for children or adults suspended or revoked? YesNoPlease give anexplanation on the back of this pagefor any “yes” answer or for Anyquestion that you did not understand orany question you do not know how to answer.7. Lived outside of the State of Washington in the last two years?Yes No If yes, where? _________________________________________________________________________________________How long have you lived continuously in Washington State? _____________________________________________________________________Do you currently attend a church? If so, which one?____________________________________________________________________________List names and addressesof other churches you have attended regularly during the past five years:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Personal References:(PLEASE EXCLUDE RELATIVES)Name:_______________________________________________ Name: _______________________________________________Address: _____________________________________________ Address: _____________________________________________Telephone: ___________________________________________ Telephone: ___________________________________________Email: _______________________________________________Email: _______________________________________________Applicant’s StatementUnder penalty of perjury, the information Ihave given in this application is correct and complete to the best of my knowledge. I agreethat false information or significant omissions may disqualify me from further consideration for my service and may be consideredjustificationfor dismissal if discovered at a later date.I authorize any references or churches listed in this application to give you any information (including opinions) that they may haveregarding my character and fitness for child/youth work. I release all such references from any liability for furnishing suchevaluations to you, provided they do so in good faith and without malice. I waive any right that I may have to inspect referencesprovided on my behalf.Should my application be accepted, I agree to be bound by the policies of First Class Christian Homeschool Co-op,and to refrain from unscriptural conduct in the performance of my services on behalf of the organization. I give permission to First Class Christian Homeschool Co-op to run a background check every two years. I understand that the information given on my original application will be used.Applicant’s Signature: ______________________________________________________________ Date: ________/________/________
  2. Identification and Criminal History Section PO Box 42633, Olympia WA 98504-2633REQUEST FOR CRIMINAL HISTORY INFORMATION CHILD/ADULT ABUSE INFORMATION ACT RCW 43.43.830 THROUGH 43.43.845 REQUESTING AGENCY/ADDRESS PURPOSECheck appropriate boxAgency Educational School District (ESD)/School District Attn Volunteer – no feeNon-Profit Business/Organization – no fee Address (Excluding Schools & ESD’s)Profit Business/Organization - $17City/State/Zip Adoptive Parent - $17I certify this request is made pursuant to and for the purpose indicated. Receive background results electronicallyEmail address Password (must be at least 8 characters)Authorized Signature Date Fees: Make payable to Washington State Patrol by check, money order, or business account. ( ) Notary letters certifying the results are available upon request. There is an additional $10.00 processing fee per notary seal. TitleArea Code/Phone NumberNotarized Letter(s) APPLICANT OF INQUIRY (Please provide as much information as possible; name and date of birth are mandatory.)Applicant’s Name: Last First Middle Alias/Maiden Name(s): Date of Birth: Sex: Race: Month/Day/Year Secondary dissemination of this criminal history record information response is prohibited unless in compliance with statute. WASHINGTON STATE PATROL IDENTIFICATION & CRIMINAL HISTORY SECTIONAs of this date, the applicant named below has no record pursuant to RCW 43.43.830 through 43.43.845. Requesting Agency Applicant’s Signature Applicant’s Name Address City/State/Zip 3000-240-430 (R 6/12) WASHINGTON STATE PATROLA BC D First Class Skagit CountyDirector1500 E College Way, Suite A #303Mount Vernon, WA 98274✔First Class Skagit County
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