Background Check Authorization Form - Consent for Criminal Background History Check - Authorization/Waiver/Indemnity

Sep 17, 2026

Uploaded by Lute

Background Check Authorization Form for criminal history screening requires each employee or volunteer to sign an authorization/waiver/indemnity permitting Score at the Top Learning Center & School to obtain and review criminal background information. The scope includes arrest and conviction data, plea bargains, deferred adjudications, and juvenile delinquency conduct. The information may be used to assess eligibility for employment or volunteer placement and may be rechecked during service. The applicant affirms truthful responses and agrees to indemnify and hold harmless the organization and related parties for claims arising from the investigation.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Consent and Authorization

Applicant Acknowledgements

Waiver and Indemnification

Signature and Applicant Information

Address History

Background Check Authorization Form Consent for Criminal Background History Check Authorization/Waiver/Indemnity Each employee or volunteer to be screened must sign an authorization/waiver/indemnity form, giving approval for Score at the Top Learning Center & School to perform a criminal background check. I hereby give my permission to Score at the Top Learning Center & School to obtain information relating to my criminal history record. The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications and delinquent conduct committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by Score at the Top Learning Center & School and a procedure is available for clarification if I dispute the record as received. I also understand that the criminal history could contain information presumed to be expunged. I hereby affirm that my answers to the foregoing questions are true and correct and that I have not knowingly withheld any fact or circumstances that would, if disclosed, affect my application unfavorably. I understand that any false information submitted in this application may result in my discharge. I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify the Score at the Top Learning Center & School and each of their officers, directors, employees and agents and hold them harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever (including claims for negligence, gross negligence, and/or strict liability of the Score at the Top Learning Center & School ) and any and all related attorneys’ fees, court costs and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/staff member. Applicant’s Signature Date Applicant’s Printed Name (last, first) List maiden name or any other name used Gender M / F DOB (MM/DD/YYYY) / / SSN - - [Remainder of Page Intentionally Left Blank] Background Check Authorization Form Consent for Criminal Background History Check Authorization/Waiver/Indemnity Address History (past 5 years required) | Current Address, \# years at this address : | | --- | | Previous Address, \# years at this address : | | Previous Address, \# years at this address : | | Previous Address, \# years at this address : | | Previous Address, \# years at this address : |

FAQs

What information does the form authorize Score at the Top Learning Center & School to obtain for a criminal background check?

The form authorizes obtaining information relating to the applicant’s criminal history record, which may include arrest and conviction data, plea bargains, deferred adjudications, and juvenile delinquency conduct.

How will the criminal history information be used?

The information will be used, in part, to determine eligibility for an employment or volunteer position. The check may be repeated at any time while the applicant remains an employee or volunteer.

What responsibilities and consequences does the form state for the applicant’s answers and submissions?

The applicant affirms that answers are true and correct and has not knowingly withheld facts that could affect the application. False information may result in discharge, and the applicant agrees to indemnify and hold harmless the organization and related parties for claims arising from the investigation.

Sep 17, 2026

Uploaded by Lute