About Worthington United Methodist Church

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Policies

Safe Sancturary -- Child Protection Policy

Safe Sanctuary Policy Sections: Intro, Philosophy & Mission <> Definitions <>
Preventing Child Abuse <> Reporting the Incident
Appendices: Appendix A <> Appendix C <> Appendix D <> Image Release Form

AppendixD

Authorization and Request for Criminal Records Check

I, ____________________, hereby authorize Worthington United Methodist Church to request the Worthington police department, Franklin County Sheriff's department, or any police or sheriff's department, or any other company, to release information regarding any record of charges or convictions contained in its files, or in any criminal file maintained by me, whether said file is a local, state, or national file, and including but not limited to accusations and convictions from crimes committed against minors, to the fullest extent permitted by state and federal law. I do release said police/sheriffs department, or any other company, from all liability that may result from any such disclosure made in response to this request.

Signature of Applicant:Date:

Print applicant's full name:

Print all other names that have been used by applicant, if any:

Date of Birth:Place of Birth:

Social Security Number: (attach copy) :

Drivers License Number: (attach copy) :License Expiration Date:

Request sent to:

Name:

Address:

Phone:

List each address at which you have resided in the last five years:
Address:

Address:

Applicant's Current Name:

Phone:Email: