Background Check Authorization Form

Transcripción

1 Youth of the Year Background Check Authorization Form Youth of the Year winners embody service, leadership and character and serve as peer leaders, role models and Club spokespersons. This form helps Boys & Girls Clubs and Boys & Girls Clubs of America maintain the integrity of the Youth of the Year program. All participants selected as Youth of the Year at the Club organization level must have a valid state-issued identification card. Each state winner (and his or her parent or legal guardian if the participant is a minor) must give consent for a background check to be completed by the winner s organization prior to being advanced to regional-level competition. If you have been named a State Youth of the Year, please complete all sections of this form, sign and return to your Club advisor to ensure you can be advanced to regional-level competition. Name (please print): (Last) (First) (Middle) Maiden or Alias Names: Social Security No.: Date of Birth (mm/dd/year): Sex (m or f ): Please list addresses (street address, city, state, ZIP) and dates at each for the past seven years: Current: Previous: Previous: Previous: Previous: I hereby authorize ( fill in Club organization name), Boys & Girls Clubs of America and/or ( fill in name of background check service provider) 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 Youth of the Year Nomination Form is current and accurate. I release ( fill in Club organization name), Boys & Girls Clubs of America and/or ( fill in name of background check provider) and any person or entity which provides information pursuant to this authorization, from any and all liabilities, claims or lawsuits in regard to the information obtained from any and all of the above-referenced sources. I certify that the following is my true and complete legal name and all information contained herein is true and correct to the best of my knowledge. Signature Signature of Parent/Legal Guardian (if Youth of the Year is a minor)

2 Formulario de Autorización para la Investigación de Antecedentes del Joven del Año Los ganadores del programa Joven del Año simbolizan el servicio, el liderazgo y el carácter, además de que sirven como portavoces del Club, líderes y modelos a seguir. Este formulario ayuda a los Boys & Girls Clubs y Boys & Girls Clubs of America a preservar la integridad del programa Joven del Año. Todos los participantes que sean seleccionados como Joven del Año por su organización deben tener una tarjeta de identidad válida proveido por el estado. Cada ganador a nivel estatal (además de su padre/guardian legal en caso de que el participante sea menor de edad) deben otorgar su consentimiento para que se realice una investigación de sus antecedentes antes de que puedan continuar con la competencia a nivel regional. Si usted ha sido nombrado Joven del Año al nivel estatal, por favor llene todas las secciones del formulario, fírmelo y devuélvalo a su asesor del Club para poder avanzar a la competencia a nivel regional. Nombre (escribir con letra de imprenta): (Apellido) (Primer Nombre) (Segundo Nombre) Nombre de Soltera o Alias: Número del Seguro Social: Fecha de Nacimiento (mes/día/año): Género (m ó f ): Enliste las direcciones (calle, ciudad, estado, código postal) y las fechas de los sitios donde ha vivido durante los últimos siete años: Actual: Anterior: Anterior: Anterior: Anterior: Autorizo a (anote el nombre de la organización del Club), a Boys & Girls Clubs of America y/o a (anote el nombre del proveedor de servicios de investigación de antecedentes) para que realicen una investigación independiente de mis antecedentes, referencias, carácter, empleos previos, educación y antecedentes criminales o policiacos, incluyendo aquellos pertenecientes a organizaciones públicas y privadas, además de cualquier registro público, esto con el fin de confirmar la veracidad y la vigencia de la información que consta en mi Formulario de Nominación del Joven del Año. Libero a (anote el nombre de la organización del Club), a Boys & Girls Clubs of America, a (anote el nombre del proveedor de servicios de investigación de antecedentes) y/o a cualquier persona o entidad que proporcione información conforme a esta autorización de cualquier responsabilidad, reclamación o demanda con respecto a la información obtenida de cualquiera de las fuentes anteriormente enlistadas. Certifico que el siguiente es mi nombre completo, legal y verdadero y que toda la información contenida en este documento en mi opinión es verdadera y correcta. Firma Firma del Padre/Guardian Legal (si el Joven del Año es menor de edad)

3 Nomination Form Instructions For Office Use Only Received Region State D.E. The following pages (1-9) provide an opportunity to give specific examples of the nominee s eligibility for State, Regional and National Youth of the Year. Please attach no more than two supporting letters for each category to the appropriate page. You may substitute one newspaper article for one letter. This form must be completed in full. Date Male Female Last Name of Nominee First Name Middle Initial Date of Birth Social Security Number Length of Club Membership Name of High School Projected Graduation Date (Month/Year) Tentative College Choice Anticipated Career Choice Home Address No. of Volunteer Hours (in last 12 months) City State Zip Code Telephone Number with Area Code I (we) hereby consent to print and online publication and use of photographs and information contained in this application form and photos and video taken during the entire Youth of the Year process from local to national by Boys & Girls Clubs of America or its agents. I (we) hereby attest that all information contained in this application form and attached supporting materials is to the best of my (our) knowledge truthful, accurate and complete, and that nominee meets all eligibility requirements of the Youth of the Year program. Signature of Nominee Signature of Parent or Legal Guardian Name of Boys & Girls Club Organization Address Address City State ZIP Code Telephone Number with Area Code Fax Number with Area Code Name of Chief Professional Officer Signature of Unit Director, if applicable Signature of Chief Professional Officer Note: Each organization, including individual units of each organization, is encouraged to submit a candidate for competition in the Youth of the Year Program. Use a separate form for each nomination. Applications and materials will not be returned.

4 HOME AND FAMILY Give examples of how the nominee has demonstrated leadership and service in the home and family. Be specific. You may attach no more than two supporting letters for this category. You may substitute one newspaper article for one letter. Please note: Letters or articles may be submitted as additional documentation but may not be substituted for the required written narrative. 2

5 MORAL CHARACTER 3 Adherence to high moral standards should be described. Examples include positive peer-to-peer interaction, community service, involvement in extracurricular activities or involvement in a faith community. You may attach no more than two supporting letters for this category. You may substitute one newspaper article for one letter. Please note: Letters or articles may be submitted as additional documentation but may not be substituted for the required written narrative.

6 COMMUNITY 4 Give examples of how the nominee has demonstrated leadership and service in planning and implementing community activities. You may attach no more than two supporting letters for this category. You may substitute one newspaper article for one letter. Please note: Letters or articles may be submitted as additional documentation but may not be substituted for the required written narrative.

7 SCHOOL 5 Give examples of how the nominee has demonstrated school leadership and service. Activities engaged in and their diversity, scholastic achievement and contributions made to school, faculty and peers should be highlighted. Attach official school record indicating course of study, grades, class standing and achievement. You may attach no more than two supporting letters for this category. You may substitute one newspaper article for one letter. Please note: Letters or articles may be submitted as additional documentation but may not be substituted for the required written narrative.

8 SERVICE TO CLUB 6 Give examples of how the nominee has demonstrated leadership and service within your Club. The length of membership, activities engaged in, responsibilities assumed, influence on peers and assistance to staff should be reported. You may attach no more than two supporting letters for this category. You may substitute one newspaper article for one letter. Please note: Letters or articles may be submitted as additional documentation but may not be substituted for the required written narrative.

9 LIFE GOALS 7 Give examples of how the nominee has demonstrated initiative and leadership potential in setting and achieving short- and long-term goals. Highlight instances in which the nominee has demonstrated perseverance and the ability to make sound decisions that support his or her goals. Describe the nominee s long-term life and career aspirations. You may attach no more than two supporting letters for this category. You may substitute one newspaper article for one letter. Please note: Letters or articles may be submitted as additional documentation but may not be substituted for the required written narrative.

10 ESSAY ONE 8 The applicant is asked to write an essay on what the Club means to him or her, to be written in the words of the nominee. Judges will consider content and grammar. Type essay on this application form and attach original of essay written in the nominee s handwriting.

11 ESSAY TWO 9 The applicant is asked to write an essay on why a post-high school education is important to him or her, to be written in the words of the nominee. Judges will consider content and grammar. Type essay on this application form and attach original of essay written in the nominee s handwriting.