CONSENT TO RELEASE OF CONFIDENTIAL INFORMATION

I desire to work with Children/Youth or Security at First Baptist Church of Charlotte, Michigan and wish the church to be informed as to my past record and character. I therefore authorize any persons, references, employers, church or organizations with whom I have had contact to release to the church any information. This includes information they may have regarding my record, character, and fitness for children/youth/security work. I also authorize this church to contact any law enforcement or social service agency to determine whether I have been charged or convicted of a crime. I authorize such agencies to release such information to the church. I release the church and its agents, as well as all persons, organizations, and agencies from liability for any damage that may result from exchanging such information. I waive any right I may have to inspect such information provided on my behalf, except information that is a matter of public record.

PLEASE USE YOUR FULL LEGAL NAME

First Name

Last Name

Middle Initial

Maiden name

Other name

Date of Birth

Sex

Ethnicity

Driver's License Number

State

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Digital Signature Consent

Your Signature

Date Input

Witness Signature

Date Input

You will need to call the church office with your Social #, leaving a message is OK: 517.543.6900

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