Criminal Background History Check - Authorization for Release

1. Explanation and Instructions:

In order to help safeguard girls in our care, Girl Scouts of the Commonwealth of VA, Inc. (GSCV) conducts criminal background history checks
on its board members, and volunteers who come in contact with girls, money or product. Information obtained is confidential as provided by law
and will be used and retained only as authorized by law.
You must complete this release form to be considered for any position. Any volunteer appointment is contingent upon the completion and
review of a criminal background check. Any question left blank may result in incorrect information about your criminal background history. Also, it
may delay the processing of your application. You may also complete this application and background screening online at comgirlscouts.org.

2. Authorization to Release Information:

I hereby give my permission to Girl Scouts of the Commonwealth of VA to obtain information relating to my criminal history record through a
vendor or agency selected by GSCV. The criminal history record, as received from the report agencies, may include arrest and conviction data,
plea bargains, deferred adjudication, as well as social security verification. It may also include information regarding driving history. I understand
this information will be used, in part, to determine my eligibility for a volunteer position with this organization. I also understand that as long as I
remain a volunteer here, the criminal history background check may be repeated at any time. I understand I will have a limited opportunity to
review the criminal history and a process is available for clarification if I dispute the record as received. I hereby release and agree to indemnify
Girl Scouts of the Commonwealth of VA, Inc. and each of their officers, directors, employees and agents harmless from and against any and all
liability, expense (including court cost and attorneys fees) and claims for damage of any nature whatsoever resulting from the investigation of my
background in connection with my application to become a volunteer or employee.

Personal Information:
First Name:

Middle Name:

Date of Birth:

Maiden Name:

Drivers License Number and State of Issue:

Social Security Number:

Address:
Phone Number:
Service Unit:

Last Name:

City:

State:

Zip Code:

E-mail Address:
Troop Number:

*Membership Consultant Name

*E-mail notification that your background check has been completed and application has been received will be sent to your membership consultant.

In the selection of volunteers, there shall be no discrimination against an otherwise qualified individual on the basis of race, color, ethnicity,
sex, religion, creed, national origin, socioeconomic status, age, disability, marital status, veteran status, or on any other basis prohibited by
state or local law.
I hereby authorize you to check all my educational, personal, and employment references.
While serving as a volunteer with GSCV, I will notify my council supervisor of any arrests or convictions that may restrict my volunteer activities
including traffic violations, misdemeanors and felonies.
I certify that my answers to the preceding questions are true and complete and that I have not knowingly withheld any information that might, if
disclosed, affect my application unfavorably. I understand that any misrepresentation or omission of facts on this application will be cause for
rejection of this application or later dismissal.

Applicants Signature:
When completed, mail, fax, or email this application to:
GSCV
Attn: Kelsi Ramdeo Dir. Of Volunteerism
4900 Augusta Ave Ste 200
Richmond, VA 23230
Bgcheck@comgirlscouts.org or fax 804-340-2910

Date:
Id like to make a contribution to GSCV and will pay
$15.95 for the cost of my background screening . I
have mailed a check made out to GSCV.
I am unable to pay for the cost of the screening at
this time, GSCV please cover the cost for me.