CBC Voluntary Disclosure Form

Camp Beech Cliff Voluntary Disclosure Form

Please complete and submit the form below. If you are conditionally offered a position you will receive a separate link to complete a Background Check Request.
Click here to download a copy of A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and STATE LAW NOTICES AND DISCLOSURES
Full Name*

First NameMiddle NameLast NameSuffix
Other names by which known/Alias (e.g., maiden name)
E-mail*

Confirmation Email
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
List any other addresses during past seven years (Please note, addresses should include anywhere that you lived for an extended period of time. College Addresses, or seasonal addresses must be included):
Social Security #*
Birthdate*

MonthDayYear
Driver's License # and issuing state

STATE LAW NOTICES AND DISCLOSURES – BACKGROUND INVESTIGATION
CALIFORNIA applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check the box if you would like to receive a copy of the investigative consumer report or consumer credit report at no charge if one is obtained by the Company.

Check box to receive report.
NEW YORK applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting One Source The Background Check Company, PO Box 24148, Omaha, NE 68124, 1.800.608.3645, www.onesourcebackground.com.
NEW YORK applicants or employees only: By signing below, you also acknowledge receipt of a copy of Article 23-A of the New York Correction Law.
WASHINGTON applicants or employees only: You have the right to request from The Background Check Company, a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
MASSACHUSETTS, MINNESOTA and OKLAHOMA applicants or employees only: Please check the box if you would like to receive a copy of your consumer report, free of charge, if one is obtained by the Company.Check box to receive report.

Check box to receive report.

I also understand that:
- The camp may deny employment to any person who answers “yes” to any one of questions 1-5. If hired and the employer later discovers circumstances that would indicate a “yes” answer to any of the above questions, employment may be terminated immediately.
- The information provided on this form is subject to verification, which may include a criminal history check and request from any Central Registry of Child Abusers.
- The camp may terminate employment or volunteer service of any person if that person is found, regardless of when discovered, to:
  -have a history of complaints of abuse of a person(s) under the age of 18;
  -have resigned, been terminated, or been asked to resign from a position whether paid or unpaid, due to complaint(s) of sexual abuse of a person(s) under the age of 18; and/or
  -have falsified or omitted information in this disclosure statement.
- This disclosure statement must be updated yearly.
I agree to Camp Beech Cliff's terms and conditions*

Yes
Applicant Signature - I agree to Camp Beech Cliff’s terms and conditions*

Clear
Date of applicant's signature

MonthDayYear
DateHourMinutesAM/PM Option
Signature of Parent/Guardian (If applicant is under 18 years of age)

Clear
Date of parent/guardian's signature

MonthDayYear
DateHourMinutesAM/PM Option
Click here to download a copy of A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and STATE LAW NOTICES AND DISCLOSURES
Should be Empty:

Camp Beech Cliff Voluntary Disclosure Form