• Camp Tecumseh YMCA Consent to Background Check

  • I authorize YMCA Camp Tecumseh to conduct a criminal background check and a check of the sex offender registry of all fifty states as a condition of my employment. This check includes the following: Criminal history, reference searches for felony and misdemeanor convictions at the county, state, and federal levels of every jurisdiction where I currently reside or where I have resided, and sex offender registry searches at the county, state, and federal levels in every jurisdiction where I currently reside or where I have resided.
    I understand and agree that the results of my background check may affect the employment decision of YMCA Camp Tecumseh, and I hereby release YMCA Camp Tecumseh from any and all claims which may result from my background check results.
    I also understand that the Background Check Policy is subject to change without notice, in order to maintain compliance with government and industry standards, and company policy.
    I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without previous notice.
    If I am hired or serve as a volunteer, whichever is applicable, such background checks may be obtained at any time after receipt of this disclosure and authorization and throughout the course of my employment and volunteer service, as permitted by law and unless revoked by me in writing.
    Camp Tecumseh wants to take every step possible to ensure that our children and guests are placed within the hands of caring, loving staff. As a prospective employee of Camp Tecumseh YMCA, I understand that it is this organization’s policy to secure criminal history information as part of their hiring process, using the information provided below.

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Voluntary Disclosure

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Previous residence(s) for last five years (include college and home residences):

  • Have you ever been convicted of any crime relating in any manner to children and/or your conduct with them?*
  • Have you ever been convicted of any crime including, but not limited to, those listed below and/or any crime similar in any manner to those listed below?*

    • Indecent assault and battery on a child under fourteen

    • Indecent assault and battery on a mentally retarded person

    • Indecent assault and battery on a person who has obtained the age of fourteen

    • Rape

    • Rape of a child under sixteen with force

    • Assault with intent to commit rape

    • Kidnapping of a child under sixteen with intent to commit rape

    • Distribution and trafficking of narcotics or other controlled substances

    • Intent to commit any of the above crimes.

  • Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children?*
  • Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection?*
  • Have your parental rights ever been terminated for reasons involving sexual or physical abuse of children?*

  • I understand that:

     

    1. The camp may deny employment to any person who answers “yes” to any one of questions 2-6. 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.
    2. 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.
    3. The camp may terminate employment or volunteer service of any person if that person is found, regardless of when discovered, to:
      1. have a history of complaints of abuse of a minor;
      2. 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 minor; and/or
      3. have falsified or omitted information in this disclosure statement.

    This disclosure statement must be updated yearly.

  • Should be Empty: