AUTHORIZATION AND RELEASE
I authorize the Baptist State Convention of North Carolina or any agent of the Baptist State Convention of North Carolina
(collectively “the Convention”) to obtain records related to me from criminal justice agencies and/or to obtain a consumer
report from a consumer reporting agency or other agency. I understand that the information obtained may include, among
other things, information regarding criminal convictions and charges. I understand that this information will be obtained
for the purpose of determining my suitability to volunteer in the capacity designated below. I hereby release the
Convention from any liability in obtaining and utilizing such information.
I hereby authorize any party or agency contacted by the Convention to furnish the above-described information, and I
release from liability any party or agency who provides such information to the Convention.
I understand that failure to provide all or part of the information requested below may result in my disqualification as a
volunteer. This release shall be effective on the date of its execution and shall remain effective through the term of my
volunteer service for any future background checks that may be performed by the Convention. PLEASE WRITE
LEGIBLY AS SEVERAL DIFFERENT PEOPLE HAVE TO BE ABLE TO READ YOUR NAME.
I certify that I am at least 18 years old.
Church Name and Address: ____________________________________________________________________
Week of camp attending: ______________________________________________________________________
Position in which I will work: (check position and age preference*)
Print Name (Full Name): ______________________________________________________________________
Other Names Used (Include Maiden):__________________________________________________________
Date & Place of Birth: ______________________________________________________________________
Driver’s License #:______________________________________State