BYB Volunteer Coach Background Check Authorization Form

CITY OF BLOOMINGTON VOLUNTEER
BACKGROUND CHECK AUTHORIZATION

I hereby authorize the City of Bloomington to conduct criminal background checks to determine my eligibility for employment or continued employment.

I understand that the City is asking for my date of birth, previous names, and previous addresses only in order to conduct background checks and for no other reason.

By signing below, I hereby authorize the City of Bloomington to conduct background checks on me. I hereby release the City of Bloomington from any liability related to the procurement and/or disclosure of any information provided by me or obtained about me in connection with my application for employment with the City of Bloomington. I understand that any information gathered as a result of background checks will be kept confidential. I make this waiver knowingly and voluntarily.

What grade would you like to coach?*

Applicant's Signature*

Printed name*

other names used (if applicable)

Date of Birth*

Please confirm it is DOB and not today's date

Phone Number*

Please enter a valid phone number.

Email*

Please make sure this is an address you check regularly, should we need to send important information.

Current address (include city, state and zip code)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Address if current address is less than 1 year (include city, state, and zip code)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

City and State of Birth*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

- For Office Use Only -

Program: Bloomington Youth Basketball

Supervisor: Scott Pedersen