Volunteer Registration Form - Class A - Special Olympics North Dakota (Page 2 of 2) in pdf

Please read the following:



In the course of volunteering for Special Olympics, I may become aware of personal information, and I agree to

keep said information in the strictest confidence.



I grant Special Olympics North Dakota permission to use my likeness, voice, and words in television, radio, film

or any form to promote activities of Special Olympics.



I understand that the relationship between Special Olympics North Dakota and volunteers is an “at will”

arrangement and that I may be terminated at any time, without cause, by Special Olympics North Dakota.



I will notify Special Olympics North Dakota of any change to the information I have provided on this application

within 90 days of occurrence.

AUTHORIZATION AND RELEASE FOR CRIMINAL AND OTHER BACKGROUND RECORD CHECK

I certify that the information provided is true and complete to the best of my knowledge. I have not withheld any

information that could affect my application unfavorably, if included. I understand that in connection with my

application to provide services as a volunteer, and/or for continuous volunteer services for Special Olympics North

Dakota (SOND), General Information Services, Inc., their agents, assigns or any other authorized third parties

(collectively, “the Investigators”) and/or local and state law enforcement agencies may be performing, requesting,

obtaining or conducting a background check on me. This background check may include an inquiry into my employment

history, education, general character or reputation, work experience, driving, and/or criminal history (the

“Information”).

I understand that SOND may rely on any part or all of this information in determining whether to extend an offer of

volunteer duties to me. I further understand that if any adverse action is taken by SOND or if SOND chooses not to

extend an offer of volunteer duties to me based upon the Information, that I will be provided a copy of such

information.

I have read this ADULT CLASS A VOLUNTEER APPLICATION AND RELEASE FOR CRIMINAL AND OTHER BACKGROUND

RECORD CHECK and by signing below, hereby authorize investigators to conduct a background check as described

herein in conjunction with my application for volunteer duties. I further direct and authorize the investigators to

conduct the background check and further authorize any third parties or agencies who may be the custodians of or in

possession of the requested information, to disclose such information to investigators in connection with this

background check. This form is intended to be, among other things, a criminal conviction release authorization, and I

hereby authorize the investigators to receive my criminal record(s).

I understand that the background check as described above will be conducted again on or after the cycle date of this

application and every cycle period thereafter unless I am no longer seeking Adult Class A Volunteer status, in which

case I will notify Special Olympics North Dakota.

Special Olympics North Dakota may refuse to allow me to volunteer if I provided any incorrect information or omission.

I WAIVE, RELEASE AND DISCHARGE Special Olympics North Dakota, its officers, directors, employees, volunteers,

agents and representatives from any liability for all damages and losses of whatever kind or nature that may result in

connection with Special Olympics North Dakota conducting a criminal history records check or motor vehicle driving

records check on me.

I understand that my volunteer service can be modified or terminated with or without notice or cause, at any time, at

the option of Special Olympics North Dakota or at my option and that Special Olympics North Dakota may, in its sole

discretion, decline to accept my application for volunteer with or without cause.

Volunteer’s Signature: ______________________________________

Date: ___________________

Signature of Parent or Guardian if Volunteer is a Minor __________________________ Date ___________

Print Full Name of Parent or Guardian ___________________________________________________________

For office use only

Protective Behaviors Training completed _____ yes _____ no

Date _________

General Orientation completed _____ yes _____ no Date ________

ID check completed _____yes _____ no Initials ________________

Background check: _____ Declined

______ Approved Class A Date _______ Initials ______

Volunteer Registration Form - Class A - Special Olympics North Dakota Page 2

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