Consent For Criminal Background History Check
Authorization / Waiver / Indemnity
APPLICANT INFORMATION:
Applicant Full Name (Last, First, MI)
Maiden or Other Name(s) Used
Current Address
City
Social Security Number
-
State
Date of Birth
/
/
Zip Code
Driver’s License Number
County
State Issued
I hereby authorize Big Country Baptist Assembly (BCBA) and/or its Service Provider to request and receive any and all
background information about or concerning me, including but not limited to my Criminal History, Social Security
Number Trace including a consumer report under the Fair Credit Reporting Act, 15 U.S.C 1681, Driving Record,
Employment History, Military Background, Civil Listings, Educational Background, Professional License from any
Individual, Corporation, Partnership, Law Enforcement Agency, and other entities including my Present and Past
Employers.
The criminal history, as received from the reporting agencies, may include arrest and conviction data as well as plea
bargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand that this information
will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also
understand that as long as I remain an employee or volunteer here, the criminal history check may be repeated at any time.
I understand that I will have an opportunity to review the criminal history as received by client/agency and a procedure is
available for clarification, if I dispute the record as received. I also understand that the criminal history could contain
information presumed to be expunged.
I further release and discharge BCBA and their Service Provider and all of their Subsidiaries, Affiliates, Officers,
Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request for
information or records pursuant to this authorization, procurement of an investigative consumer report and understand that
it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever
are applicable.
I understand that I have the right to make written request within a reasonable period of time to BCBA for additional
information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided the
above information for employment/volunteer purposes, and I have carefully read and understand this authorization.
Print Name: ________________________________________________________
Signature: ________________________________________ Date _____________
Big Country Baptist Assembly
Personal data: please print
Current church membership: __________________________________ City ____________________________
Pastor’s name and contact phone number: ________________________________ (
Do you consider yourself as a regular attendee at your church? Yes or
) ______-__________
No
Email Address: _____________________________________________________________________________
My space/facebook or twitter URL:
__________________________________________________________________________________________
Describe previous experience doing manual labor: (cleaning toilets, vacuuming carpets, washing dishes,
mowing, weed-eater, mopping floors, dumping trash, etc.)
Do you have any physical condition that would limit your doing manual labor? Yes or
describe in detail:
No, if so, please
What has prompted you to consider being in ministry here at BCBA?
Have you been in a paid ministry position before, if so where & what positions?
Have you ever been arrested? If yes, explain. Give date and reason(s).
Have you ever been convicted of any charges against children, unlawful sexual offense, assault, or any
felony charges? If yes, describle.
Moral Conduct Code:
Marital status: (circle one) Single Married Separated Divorced Widowed
Do you have anyone from the opposite sex, or same sex that isn’t listed on my W-4 form living with you?
Yes or
No
Should there be someone living in my home, my relationship is not a hindrance to others and is not in
violation with what God’s Word says about relationships between each other.
BCBA considers all positions of employment at BCBA ministry positions. Ministers
are held to higher, “above reproach standards”, than non-ministers (Romans 14,
1 Corinthians 10:28, Titus, and other scripture). For this reason, I agree that alcohol
consumption; tobacco use, profanity, and/or open appearances of other immorality
are viable reason for dismissal from employment from BCBA.
Signature of Employee: ______________________________________________________________________
Staff Health Consent and Release Form
Name______________________________________________________________________________
Address____________________________________City____________ST_____Zip_______________
Birthdate _____/_____/________
Gender:  Male  Female
Age: ______________
Height: _______ft. _______in.
Weight: ___________lbs.
Parent's/Legal Guardian’s Name: _______________________________________________
Home Phone: (______) ______ - __________ Work Phone: (______) ______ - __________
Email: _______________________ @ _____________ . ______
Dr.’s Name: ___________________________ Phone: (______) ______ - ________
If you have any significant health issues or newly developed concerns after turning in this form please
notify Big Country Baptist Assembly (BCBA) Staff detailing care and/or limitations.
IMMUNIZATIONS **Dates are required for anyone under 18 years of age** :
Polio(Date)______________
DPT(Date)______________
Measles(Date)____________
Mumps(Date)____________
Rubella(Date)____________
Tetanus (Date)____________
HEALTH HISTORY - List any recent illnesses, injuries and/or hospitalizations relevant to a physician in case
of an emergency (attach extra sheet if necessary)
________________________________________________________________________________________
________________________________________________________________________________________
ALLERGIES:____________________________________________________________________________
If you have any food allergies or special nutritional needs you are expected to list and discuss your issues.
MEDICATIONS now being taken: ___________________________________________________________
I give my permission for the Camp Health Officer / Full-Time Staff to give the over-the-counter medications I
have circled in accordance with standard label directions:
 Tylenol  Ibuprofen  Antihistamine  Decongestant  Cough Medicine
I hereby authorize the BCBA staff or Camp Health Officer to make emergency medical decisions for my health
and I understand that my insurance coverage will be primary coverage for all illnesses and accidents. BCBA
does carry Worker’s Comp Insurance for work-related accidents.
__________ Employee Initials
Insurance in Name of: _____________________________ Company: _______________________________
Insurance Policy #: ________________________
Phone: (______) _______ - __________
Address: _____________________________ City: ______________ State: ____
Zip: ____________
If parent cannot be reached in an emergency, please contact:
Name: ______________________ Phone: (______) ______ - __________ Relationship:_________________
Name_______________________ Phone: (______) ______ - __________ Relationship_________________.
If there are any activities I am not physically able to do, I have listed them here:
_________________________________________________________________________________________
I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE
ENCOUNTERED ON SAID ACTIVITY, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT
THERETO. I do hereby indemnify and hold harmless the five parent Baptist Associations and BCBA, and their
officers, directors, agents, employees, volunteers and representatives (the “Indemnified Parties”) from and
against any and all liability, damages, actions, cause of action, claims, losses and/or expenses, including but not
limited to attorneys fees, court costs and expenses, arising in connection with or based on injury to or death of
any persons or property, including the loss of use thereof, caused in whole or in part by any member of the
Group or the Group Leadership, regardless of whether or not caused in whole or in part by the negligence of the
indemnified parties, or any one or more of them. However, this indemnification shall not apply to willful
misconduct committed by the Indemnified Parties.
I further give permission and consent to BCBA for any photographs, videotapes and interviews to be taken
during the camping session to be published and used to illustrate, report, promote and advertise the camp
including on Internet Web Sites promoting or reporting on the camp. I hereby assign full copyright of these
photographs to BCBA with the reproduction either wholly or in part. I agree that they can be used separately or
together, either wholly or in part, in any way and in any medium. Provided my name is not mentioned in
connection with any other statement or wording which may be attributed to me personally, I undertake not to
prosecute or to institute proceedings, claims or demands against BCBA or any of their employees related to any
actions of BCBA taken in accordance with this paragraph.
I agree that venue for any dispute or cause of action arising between the parties, whether out of this agreement
or otherwise, can only be brought in a court of competent jurisdiction located in Shackelford County, Texas, and
such dispute or cause of action shall be governed by and construed in accordance with the laws of the State of
Texas, exclusive of any provisions relating to conflict of laws.
I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as
permitted by the law of the State of Texas and that if any portion thereof is held invalid, it is agreed that the
balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement
between the parties hereto and the terms of this release are contractual and not a mere recital.
I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE
CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding
agreement, which I have read and have understood.
Employee _____________________________________________ Date _____________
TOBACCO, DRUG AND ALCOHOL ABUSE POLICY
Purpose
The objective of this policy is to develop a drug and alcohol free workplace which will help insure a safe
and productive workplace and provide education and treatment to our employees. In order to further
this objective, the following rules regarding alcoholic beverages, as well as inhalants and illegal drugs in
the workplace have been established.
Policy
1. Alcoholism and other drug addictions are recognized as diseases responsive to proper treatment, and
this will be an option as long as the employee cooperates.
2. The manufacture, distribution, dispensing, possession, sale, purchase or use of a controlled substance
on Big Country Baptist Assembly (BCBA) property is prohibited.
3. Being under the influence of alcohol, inhalants, or illegal drugs on BCBA property is prohibited. The
unauthorized use or possession of prescription drugs or over-the-counter drugs on BCBA property is
prohibited.
4. Employees who violate this policy are subject to appropriate disciplinary action including
termination.
5. The policy applies to all employees of BCBA regardless of rank or position and includes temporary
and part-time employees.
General Policy Provisions
Any of the following actions constitutes a violation of the policy and may subject the employee to
disciplinary action including immediate termination.
1. Using, selling, purchasing, transferring, possessing, manufacturing, or storing an illegal drug or drug
paraphernalia, or attempting or assisting another to do so, while in the course of employment or
engaged in a BCBA sponsored activity, on premises, in owned, leased or rented vehicles, or on
business.
2. Working or reporting to work, conducting BCBA business or being on premises or in a BCBA owned,
leased or rented vehicle while under the influence of an illegal drug, inhalant or alcohol.
Treatment
Help for alcoholism or drug abuse or addiction can be obtained by contacting your family doctor or by
contacting any of the treatment centers listed in the Yellow Pages under Alcoholism or Drug Abuse and
Addiction. In addition, there are a number of national helplines and hotlines available to anyone wanting
help. Some of these hotlines and helplines are listed below:
NATIONAL HOTLINES AND HELPLINES
AL-ANON provides information on alcoholism and alcohol abuse and refers callers to local AL-ANON
support groups established to help friends and families of alcoholics. (1-800-356-9996) NAR-ANON
provides similar services for friends and families of drug users. (213-547-5800)
ALCOHOLICS ANONYMOUS (A.A. World Service) provides information and support to recovering
alcoholics through local chapters in communities nationwide. (212-686-1100)
THE AMERICAN COUNCIL ON ALCOHOLISM HELPLINE provides referrals to alcohol treatment
programs nationwide and provides written materials. (1-800-527-5344) pg.2
800 COCAINE is an information and referral hotline that refers callers to drug rehabilitation and
counseling services in their area. 800-COCAINE also mails out basic information on cocaine and crack.
(1-800-COCAINE/262-2463)
NARCOTICS ANONYMOUS (N.A. World Service) provides information and support to recovering drug
addicts through local chapters in communities nationwide. (818-780-3951)
THE NATIONAL COUNCIL ON ALCOHOLISM AND DRUG DEPENDENCY provides written information
on alcohol abuse and provides a referral service to treatment and counseling centers across the country.
(1-800-NCA-CALL/622-2255)
THE NATIONAL INSTITUTE ON DRUG ABUSE HOTLINE is a Federally funded service providing
referrals to drug and alcohol programs including referrals to programs for those who cannot pay for
services. (1-800-662-HELP)
DRUG FREE WORKPLACE HELPLINE provides individualized technical assistance to business, industry,
and unions on the development and implementation of comprehensive drug-free workplace programs.
(1-800-843-4971)
Coordination with Law Enforcement Agencies
The sale, use, purchase, transfer or possession of an illegal drug or drug paraphernalia is a violation of the
law. BCBA will report information concerning possession, distribution or use of any illegal drugs to law
enforcement officials. BCBA will cooperate fully in the prosecution and/or conviction of any violation of
the law.
Reservation of Rights
BCBA reserves the right to interpret, change, suspend, cancel or dispute, with or without notice, all or any
part of the policy discussed herein. Employees will be notified before implementation of any change.
Although adherence to this policy is considered a condition of continued employment, nothing in this
policy alters an employee’s status and shall not constitute nor be deemed a contract or promise of
employment.
Other Laws and Regulations
The provisions of this policy shall apply in addition to, and shall be subordinated to, any requirements
imposed by applicable federal, state, and local laws, regulations, or judicial decisions. Unenforceable
provisions of this policy shall be deemed to be deleted.
DRUG AND ALCOHOL ABUSE POLICY
EMPLOYEE ACKNOWLEDGMENT
I acknowledge that I have received a copy of the Drug and Alcohol Abuse Policy. I also acknowledge that
the provisions of the policy are part of the terms and conditions of my employment and that I agree to
abide by them.
___________________________________________________________
Print Name
___________________________________________
Employee Social Security Number
___________________________________________________________
Signature
____________________________________________
Date