Background Check Authorization

First Name(*)
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Last Name(*)
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Other names (alias, maiden, nickname)
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Email(*)
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Street Address(*)
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City(*)
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State(*)
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Zip Code(*)
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How many years have you lived at your current address? (*)
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Previous Address & dates at this location
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*If less than 7 years at current address.

Date of Birth (xx/xx/xx)(*)
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Social Security Number(*)
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Areas you would like to help with:(*)

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check all that apply

Month & year that you began regular worship service attendance at HCC(*)
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mm/yy

Do you acknowledge Jesus as Lord and Savior?(*)

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Please list the names and phone numbers of three references (no relatives)(*)
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I have read and agree to comply with HCC's Child Safety Policy.
Check(*)
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Have you completed a PA child abuse clearance in the past 5 years that you have access to?
Check(*)
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If you answered yes, please submit a copy to the church office.

Have you lived in PA consistently for the past 10 years?
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If you answered no, the church office will email you instructions on how to complete the Federal Criminal History Record search, including fingerprints. *You will not be cleared to work with children until the results are submitted.

I affirm that I have not been convicted of one or more of the 20 disqualifying crimes listed in 23 Pa. C.S. §6344 (c)(2), which generally include homicide, assault, stalking, kidnapping, sexual offenses, prostitution or child endangerment (and similar crimes) 23 Pa.C.S. § 6344.2(b.1)(1).
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What constitutes a disqualifying offense that will keep an individual from working with children will be determined by PA state law and the Pastor and/or the Board of Elders on a case-by-case basis in light of all the surrounding circumstances. Generally, convictions for an offense involving children and/or for offenses involving violence, dishonesty, illegal substances, indecency and any conduct contrary to our mission will preclude someone from being permitted to work with children. Failure to disclose a criminal conviction on the application form will also be a disqualifying event.
Any person who has been found guilty of criminal abuse violations, child molestation, aggravated assault, kidnapping, or corruption of minors in the past, regardless of the length of time since the conviction, will not be allowed to work with children or youth. This policy remains even if the sexual abuse occurred prior to the person coming to know the Lord.

If you check no because you have been convicted of any crime, please describe below, including the date of the conviction and the classification:
Explain
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Authorization to Obtain a Background Check
This form authorizes the church to obtain background information and must be completed by the applicant.
I understand that if I am approved for volunteer services by Hanover Community Church, this background authorization will be kept on file and may be used at any time during my service to procure further information when, in the judgment of Hanover Community Church, such may be necessary. By signing below I, the undersigned applicant (also known as “consumer”), authorize Hanover Community Church through its independent contractor, Protect My Ministry, to procure background information (also known as a “consumer report and/or investigative consumer report”) about me. This report may include my driving history, including any traffic citations; a social security number verification; present and former employment; present and former addresses; criminal and civil history/records; and the state sex offender records, and child abuse clearance.

In addition, I authorize Hanover Community Church and/or its agents to make an independent investigation of my background, references, character, past employment, education, criminal, or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications as a volunteer or for employment now, and if applicable, during the tenure of my volunteering or employment with Hanover Community Church.

I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification of which I am the subject upon my request to Hanover Community Church if such is made within a reasonable time from the date it was produced. I also understand that I may receive a written summary of my rights under the Fair Credit Reporting Act.

I release Hanover Community Church 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 referenced sources used.
The following is my true and complete legal name, and all information is true and correct to the best of my knowledge.

This form may be signed by digital or electronic means. In accordance with the Pennsylvania Electronic Transactions Act and the Electronic Signatures in Global and National Commerce Act, I agree that any digital or electronic signature that I apply to this form shall have the same binding effect as my handwritten signature to the fullest extent permitted under the law.

Signature(*)
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Today's Date
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Check Box(*)
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