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 ______