Calvary Chapel of Palm Harbor

Background Check Consent and Waiver Form

In consideration of my role with Calvary Chapel North Pinellas, Inc., its affiliates, integrated auxiliaries and supporting organizations, hereinafter “Calvary Chapel of Palm Harbor” and recognizing the importance of my character being above reproach, I HEREBY CONSENT TO THE FOLLOWING:

Allowing Calvary Chapel of Palm Harbor to screen me through the Florida Department of Law Enforcement or any other national, state, county, municipal agency, or private firm for the purpose of accessing and reviewing Florida and national criminal history records, driving records, references, current or prior employment as well as any other historical or background records pertaining to me.

I HEREBY WAIVE, RELEASE, AND HOLD HARMLESS FROM LIABILITY Calvary Chapel of Palm Harbor, its staff, employees, volunteers, and agents with regard to any decision that it makes on my application for involvement with Calvary Chapel of Palm Harbor based on the information I provide or that is obtained through the criminal history and background screening process.

I CONSENT to a copy of this Consent and Waiver Form being furnished to any reference that I have provided to Calvary Chapel of Palm Harbor and to any other person, organization, or entity that Calvary Chapel of Palm Harbor deems necessary in connection with its investigation of my background, character, or qualifications.

Have you ever been found guilty of any crime?

Yes

Have you ever been accused or charged with a crime or incident involving a child, the elderly, or the disabled?

Yes

Have you ever struggled with any sin involving a child, the elderly, or the disabled?

Yes

Have you ever been charged with a crime or misconduct at your workplace?

Yes

Have you ever been accused of improper conduct by an employer or as a volunteer for any reason?

Yes

Is there any other information that will be revealed through a background check?

Yes

If you answered “Yes” to any of the questions above, please provide a written explanation.

Please be prepared to discuss your answers with a pastor or overseer. By signing below I agree to immediately inform Calvary Chapel of Palm Harbor of any subsequent information, including any accusations, convictions, or other occurrences that relate to the areas of inquiry set forth above.

First Name

Last Name

Middle name

Maiden name

Date of birth