CRIMINAL RECORDS CHECK

CONSENT AND DISCLAIMER FORM

TO BE MAILED BY ASSOCIATION TO THE LOCAL POLICE DEPARTMENT

NAME (PRINT)_____________________ DATE OF BIRTH _______ SEX____

ADDRESS ____________________________________________________________________

(STREET) TOWN STATE ZIP CODE

SOCIAL SECURITY # __ __ __ - __ __ - __ __ __ __

NAME & ADDRESS OF REQUESTING AGENCY - WYSA

I AM SEEKING TO VOLUNTEER IN THE WESTERLY YOUTH SOCCER ASSOCIATION AND I REALIZE THAT I WILL BE IN DIRECT CONTACT WITH THE CHILDREN OF THIS ASSOCIATION. THIS CONTACT INVOLVES SUPERVISORY AND DISCIPLINARY POWER OVER A CHILD OR CHILDREN AND COULD INVOLVE ROUTINE CONTACT WITH A CHILD OR CHILDREN WITHOUT THE PRESENCE OF OTHER ADULTS OR LEAGUE OFFICIALS.

I REALIZE THAT IT IS RHODE ISLAND STATE LAW (40-13.2-5) THAT ALL CHILD CARE WORKERS ARE REQUIRED TO HAVE A CRIMINAL BACKGROUND CHECK PERFORMED BY THE LOCAL POLICE DEPARTMENT FOR ANY DISQUALIFYING INFORMATION WHICH COULD INDICATE AN ENDANGERMENT TO A CHILD OR CHILDREN. DISQUALIFYING INFORMATION WOULD BE A CONVICTION FOR: MURDER, VOLUNTARY MANSLAUGHTER, INVOLUNTARY MANSLAUGHTER, FIRST DEGREE SEXUAL ASSAULT, SECOND DEGREE SEXUAL ASSAULT, THIRD DEGREE SEXUAL ASSAULT, ASSAULT ON PERSONS OVER SIXTY YEARS OF AGE, ASSAULT WITH INTENT TO COMMIT SPECIFIED FELONIES (MURDER, ROBBERY, RAPE, BURGLARY, OR THE ABOMINABLE AND DETESTABLE CRIME AGAINST NATURE) FELONY ASSAULT, PATIENT ABUSE, NEGLECT OR MISTREATMENT OF PATIENTS, BURGLARY, FIRST DEGREE ARSON, ROBBERY, FELONY DRUG OFFENSES, LARCENY OR FELONY BANKING LAW VIOLATIONS.

I HEREBY AUTHORIZE THE WESTERLY YOUTH SOCCER ASSOCIATION TO REQUEST THE WESTERLY POLICE DEPARTMENT TO CONDUCT A CRIMINAL BACKGROUND CHECK ON ME, WITH THE UNDERSTANDING THAT THE WESTERLY POLICE DEPARTMENT WILL REPORT BACK TO THE WESTERLY YOUTH SOCCER ASSOCIATION ONLY WHETHER THERE WAS OR WAS NOT ANY DISQUALIFYING INFORMATION FOUND IN SAID CHECK.

I HEREBY WAIVE AND RELEASE ANY AND ALL MANNER OF ACTIONS, CAUSE OR ACTIONS, AND DEMANDS OF EVERY KIND, NATURE AND DESCRIPTION, ARISING FROM ANY RELEASE OF THIS CRIMINAL BACKGROUND CHECK, WHATSOEVER AGAINST THE WESTERLY YOUTH SOCCER ASSOCIATION AND THE WESTERLY POLICE DEPARTMENT IN BOTH LAW AND EQUITY WHICH I MAY HAVE OR IN THE FUTURE MAY HAVE.

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SIGNATURE

SIGNED AND SWORN TO BEFORE ME ON

THIS ________DAY OF ___________ 19___

IN ___________________________COUNTY

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