This form is to be completed by all applicants for any position involving supervision, custody of, or risk associated with service with minors and those with special needs. This application is used by Dream Center to help promote a safe environment for workers, minors and special needs persons who participate in our programs or use our facilities.
Please answer each question as thoroughly as possible.
Consistent with relevant law, the information on this application will not be disclosed to unauthorized persons.
Suggested references may include (1) a former or current employer, (2) a former or current co-worker, (3) friends, coaches, teachers, scout leaders. (Family members may be used, but only as one of your references)
I hereby authorize all employers, organizations, churches, and other entities and persons identified in this form to release any information contained in their files or records concerning me.
In consideration of the receipt and evaluation of this application by Dream Center, I hereby release Dream Center and any individual, youth organization, charity, employer, reference, or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply, with this authorization.
I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF, AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.
I understand and agree that it is critical to the mission of Dream Center that all employees and volunteers conform to the highest standards of safety and interpersonal conduct. I affirm that I will strictly comply with Dream Center's policies and procedures, including those concerning child safety and protection, sexual abuse and misconduct, and interpersonal relationships. I understand and agree that failure by me to abide by such policies and procedures may result in my immediate dismissal, or disciplinary action, all at the discretion of Dream Center.
My responses in the foregoing application are truthful and accurate. I understand and agree that if they are not truthful and accurate, Dream Center may determine that I am no longer qualified to be associated with its programs as a church worker, employee, or volunteer in any capacity. By signing this form, I acknowledge that I waive any right that I may have to inspect any information provided about me by any person or organization in connection with this application.
I give my permission for persons to speak freely regarding their experiences with me.
In connection with my application for placement, and at any time during the tenure of my service with Dream Center of Michigan, I understand that an investigative report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for disciplinary action or termination of past employment. I understand that as directed by policy and consistent with the job described, you may be requesting information from public and private sources about my: criminal record, driving record, education, previous employment, and personal and church references as deemed appropriate by Dream Center of Michigan.
The fact that applicants have a criminal record will not be an automatic bar to employment or work as a volunteer. Factors such as age at the time of the criminal offense, seriousness and nature of the violation, time elapsed, and subsequent rehabilitation will be taken into account.
I acknowledge that a telephonic facsimile (fax) or photographic copy shall be as valid as the original.
I hereby authorize, without reservation, any law enforcement agency, court, institution, information service bureau, school, employer, or other organization or person contacted by the employer or its agent to furnish the information described above, and release all liability resulting from such disclosure.
The following information is required by law enforcement agencies and other entities for positive identification purposes when checking records. It is confidential and will not be used for any other purpose, and kept in the most secure manner available.
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