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Walton County Parks & Recreation Department Contracted Labor I Volunteer Application' . Date of Service I Activity: Basketball T -Ball Softball Baseball Footba:1I Cheerleading Other: . Soccer Instructional Class Track & Field Age Division: Position: Official Booking Agent Scorekeeper Monitor Coach Maintenance Assistant Instructor Team Mother Gatekeeper Booster Club Officer Other: Full Legal Name: First Middle Last Age: Sex: Male Female Home Address: Street I City I State I Zip I I Home Work Other Contact: Cell Certification: (attach documentation) Agency I Organization Title Earned Expiration Date Experience: Agency I Organization Description of Service Years of Service (please complete reverse side) ---PAGE BREAK--- References: Name Agency I Organization Title Phone Number 1. Agreement: I understand that I have the right to obtain a copy of any background check report and that there is a fee involved. I also understand that I may be required to submit a classifiable fingerprint card should an initial records check reveal that I have been arrested or convicted or that I am currently charged with any offenses. I acknowledge that the Walton County Parks & Recreation Department may choose not to approve my application or have unsupervised access to a child or children pending the completion of the background check. I further agree to hold the Walton County Parks & Recreation Department and/or Walton County BOC harmless regarding any liability for defamation, invasion of privacy, or any other claim based on good faith, or action taken pursuant to the provisions of this consent. O I certify that the statements made on this application are to the best of my knowledge, true, complete, and correct. I also certify that I am legally eligible to work in the United States. Print Name Signature Date Office Use Only II II Date Received: Documents Attached Received By: Print Name Signature Reviewed By: Print Name Signature Application Approved: Application Denied: Next Review Date: ---PAGE BREAK--- SHERIFF JOE CHAPMAN WALTON COUNTY SHERIFF'S OFFICE 1425 South Madison Avenue, Monroe, Georgia 30655 Office (770) 267-6557 Fax (770) 266-1500 CRIMINAL'HISTORY/ARREST RECORD REQUEST - CONSENT FORM 1 hereby authorize Beec 0 with we PIJ--"R._ ' To receive any criminal history record information pertaining to me which may bei;'ihe files ofany State or Local Criminal Justice Agency. This authorization is valid for 90 days from the date of signature. (Last) (First) (Middle) Race Sex (Date of Birth) (If applicable, maiden name or name used in past) Social Security Number Address City/State/Zip Code Telephone # Signature Date Please circle one of the following for type of employment: Employment with mentally disabled Employment with elder care ' Employment with children Other DO NOT WRITE BELOW THIS LINE (OFFICIAL USE ONLy) This statement is to certify tbe criminal arrest files of The State of Georgia have been searched and reveal tbe following information on the above Jisted subject: ( ) No Record with our agency ( ) No record on Ga. State File/GCIC ( ) Arrest Record as follows: ( ) See attached GCIC printout WCSO# Employee Name Initials Date Received By Date