Acknowledgements and Signatures
Statement/Affirmation: In consideration of the receipt and evaluation of this application by the VA District UPCI, I agree, represent, and affirm that the information contained in this application is correct to the best of my knowledge. I authorize any references, or any other persons or organizations, whether or not identified in this application, to provide the VA District UPCI and/or is agents any information including opinions) regarding my character and fitness for youth work. I hereby release any individual, church, agency, organization, employer, reference, or any other person or organization, including record custodians, both collectively or individually, and whether or not identified in this application, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply with this authorization, excepting only the communication of knowingly false information. If my request to serve as Camp Staff member is approved, I specifically release and hold harmless the VA District UPCI, VA District Youth Department, and/or its agents and representatives, both in their individual and official capacities, from and and all liability.
Indemnification and Hold Harmless: I also agree to indemnify and hold harmless all Parties from any liability, actions, causes of actions, claims, expenses, and damages on account of injury to person or property which I now have or which may arise in the future in connection with my serving as a Camp Staff member. I expressly agree and intend that this release, waiver, and indemnity agreement is to be broad and inclusive as permitted by the law of the State of Virginia and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full force and effect. This release contains this entire contractual agreement between the parties. I further acknowledge and state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding release which I have read and understand. I further understand that a criminal records check may be conducted on me, and I consent to any such check.
Background Investigation Consent: I hereby authorize the VA District UPCI and/or its agents to make an independent investigation of my background, references, character, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming information contained on my application and/or obtaining other information which may be material to my qualifications for service now, and if applicable, during the tenure of my service. I authorize the VA District UPCI and/or its agents to discuss the results of such an investigation with my pastor. I release the VA District UPCI and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims, or lawsuits in regards to the information obtained from any and all of the above