Diocese of Crookston

ANNUAL ACKNOWLEDGEMENT AND CONSENT FORM
FOR CLERGY, VISITING CLERGY, VOLUNTEERS, EMPLOYEES, INDEPENDENT CONTRACTORS

PROVIDE ALL THE FOLLOWING PERSONAL INFORMATION (Use the TAB key to move through the form.)

I authorize the Diocese of Crookston and any of its parishes, schools, agencies, or institutions, whether or not separately incorporated, to perform a thorough background check.

I authorize the submission of my name to the Minnesota Bureau of Criminal Apprehension and/or other law enforcement agencies for the purpose of conducting a criminal background check pursuant to MN Statute 123b.03 and agree to execute any forms required by any agency for such purpose.

I acknowledge that I have been notified of the Safe Environment Policy and have received a copy of the Code of Conduct of the Diocese of Crookston. I agree to conduct myself in accordance with these policies.

I acknowledge that a violation of the Code of Conduct has consequences that could affect my continued employment or volunteer status in the Diocese of Crookston.

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1. Have you ever been convicted of a crime of sexual abuse, physical abuse, sexual harassment or exploitation? Yes
   No  
2. Has any civil or criminal complaint, or any other written complaint, ever been made against you relating to sexual abuse, sexual harassment or exploitation, or physical abuse? Yes
   No  
3. Have you ever terminated your employment, or had your employment terminated, for reasons relating to allegations or complaints (either civil or criminal) of sexual or physical abuse? Yes
   No  
4. Have you ever received any medical treatment (physical or psychological) for reasons involving physical or sexual abuse of others? Yes
   No  
5. Have you ever entered into any agreement with any past employer not to divulge the true reason for termination of employment? Yes
   No  

*If you have answered “yes” to any of the above questions, you will be contacted to provide an explanation.

PROVIDE ALL THE FOLLOWING INFORMATION:

First Name   Middle Name Last Name   Maiden or Previous Name Date of Birth       Example: 05 01 1950 Social Security Number - - Name as it appears on Social Security Card (if different from name listed above) Street Address   City   State   County   Zip Code   Telephone Number   Cell Phone Number Email Address  

If you have moved in the last twelve months, list your previous address below, if not, go on to Parish.

Street Address City State County Zip Code Signature   Date      

I understand that any false statement will be grounds for termination. I further understand that I must sign this form myself and signing this form for another person is a violation of the Fair Credit Reporting Act. This type of violation is illegal and punishable by law with civil and criminal penalties.

If you are applying for employment, volunteer service or as an independent contractor involving work that includes contact with children under the age of 18, or if you are currently employed, volunteering or working as an independent contractor in the Diocese of Crookston, involving work that includes contact with children under the age of 18, refusal to sign this form will result in rejection of your application or removal from your current position.

If this form is being used to request a background check, you may check this box to receive a copy of the report.
(The Diocese of Crookston orders background checks at the time of employment and once every five years thereafter. If we are not required to run a background check, we will not forward a background check to you.)