27912 Baker Canyon Road, Silverado, CA 92676 (714) 649-9800
(VOLUNTEER) FINGERPRINTING/CRIMINAL HISTORY
DISCLOSURE & AUTHORIZATION FORM
Santiago Retreat Center (“Santiago”) is an approved agency authorized to submit fingerprints and receive (i) California state
level criminal offender record information from the Department of Justice (“DOJ”); and (ii) federal criminal history record
information from the Federal Bureau of Investigation (“FBI”). Santiago will submit your fingerprints to the FBI and DOJ
for the purpose of performing an investigative background check, including criminal history records, on all adults serving as
a volunteer at Santiago and to evaluate your suitability for this role. Any adverse criminal information obtained may affect
your suitability. You will be provided the opportunity to complete, or challenge the accuracy of, change, and/or update the
information contained in the DOJ/FBI identification records. The procedures for obtaining a change, correction, or
updating your FBI identification records are set forth in Title 28, C.F.R. §16.34. Further information regarding these
procedures are at www.fbi.gov.
I, [print name]___________________________________________________ have carefully read, and I understand, this
Disclosure and Authorization form. By my signature below, I consent to the release to Santiago of investigative
background reports, including criminal history reports, prepared by the FBI, the DOJ, and/or all third-party agencies
providing information to these agencies (collectively referenced as “the Agencies”). If I am permitted to serve as a
volunteer at Santiago, I understand that Santiago may rely on this Authorization to obtain additional reports on me from the
Agencies during my service with Santiago without asking for my consent again, to the extent permitted by applicable law.
I also authorize all of the following to disclose to the Agencies and their respective agents all information about or
concerning me, including but not limited to my past or present employers: law enforcement and all other federal, state and
local agencies; federal, state and local courts; the military; credit bureaus; drug and alcohol testing facilities; motor vehicle
records agencies; all other private and public sector repositories of information; and any other person, organization, or
agency with any information about or concerning me.
I agree to hold Santiago harmless if the results of these searches include incorrect information that Santiago, in the exercise
of ordinary caution, would not know is incorrect. I understand that Santiago will provide more information about the nature
and scope of the report(s) if I request it.
I certify to the best of my knowledge that I have not been convicted of a crime in California or any other
state/federal/international jurisdiction and do not have any pending arrest charges.
I affirm that the fingerprints submitted will be my own and that the information provided herein is true, complete, and
accurate. I understand that dishonesty will disqualify me from consideration for serving as a volunteer at Santiago, and
such dishonesty could result in the termination of my volunteer services at Santiago.
Signature
Date
___________
_________
(Print) Full Name
___
_______
Date of Birth
___________________________________________________________________________________________________
Maiden Name and/or Other Alias Name(s) Used
______________
How Long?
Present Address
_________
Former Address
How Long?
_____
_____________________________________
Social Security Number
Driver’s License Number
1
(Rev. 6-20-16)