Staff Background Check Background & Driving Check Release Form – Staff All applicants for the Champions Staff must agree to a Background & Driving Check. There is no fee for this for Camp Staff applicants. Thanks! Background Record Check Release - StaffAll items are REQUIRED. Name* First Last Email* We'll notify you by email that we successfully received your form... Enter Email Confirm Email Address* Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific State ZIP Code Social Security Number* (format is: ###-##-####) Date of Birth* Do you have a driver's license?* No Yes Driver's License Number* License Issued in What State (ex: KS)?* Authorization for Background Check I authorize the investigation of any or all statements provided during the process of this application, and I hereby release said organization from all liability for any damages for issuing this information concerning my background. I authorize the investigation of any or all statements provided during the process of this application, and I hereby release said Organization from all liability for any damages for issuing this information concerning my background Records. I understand and agree that in the event I am offered an opportunity to serve, it is contingent upon my passing criminal background checks, the sexual offender registry check, and any other screening tests as may be required. I agree to consent to those checks at such time as designated by the Organization and to release the Organization, its directors, officers, agents or employees from any claim arising in connection with the use of such background checks. Select Today's Date* Full Signature* I'm applying for Champions Camp Staff. I have read and understand the Authorization statement above, and I hereby authorize Special Needs Health Center to conduct a required legal Background Check using my name, address, SSN, Driver's License info, and date of birth. (Add your signature using your mouse or touchscreen.)