VOLUNTEER

Having made application for volunteering at Bethany Retirement Living, and desiring them to be informed as to my previous record and character, I hereby authorize Bethany Retirement Living and its authorized representatives to obtain information relating to my activities from educational institutions, licensing agencies and all persons or entities named on my volunteer opportunity application. This information may include, but is not limited to, academic achievement, performance, attendance, personal history, discipline and conviction records. I hereby direct you to release such information upon the request of the bearer.

Further, I release any and all individuals and organizations, including record custodians, from any and all liability for damages of whatever kind or nature because of furnishing said information.

In connection with my application for volunteering at Bethany Retirement Living, I also understand that background checks may be performed on me if I receive an offer to volunteer from Bethany Retirement Living. I understand that an offer of a volunteering opportunity is conditional on the results of the background information. The background information will be obtained through:
1) http://exclusions.oig.hhs.gov/
2) http://wwwnsopw.gov/Core/Conditions.sapx
3) http://www.ndhealth.gov (Click on Nursing Homes and then click on CNA Validated Abuse List)

Certain situations may require Bethany Retirement Living to conduct a more in-depth background check. I understand the information obtained from a background check may include my past work and volunteering history, criminal history and driving record. I further understand that the background information is not limited to the current state of my residence, but may include information from any other state where I have resided.

I authorize all persons and companies contacted by Bethany Retirement Living or its representatives to provide the requested background information. I understand and agree to release the aforesaid from any liability for collecting my background information.

I understand that if adverse action is taken by Bethany Retirement Living based on the results of my criminal background check, I will be given notice orally, in writing, or electronically of such adverse action. I further understand that I may request in writing within a reasonable period of time, a complete disclosure of the nature and scope of the background investigation. I also understand that I have the right to dispute the accuracy or completeness of any information furnished by the reporting agency. I further understand that the reporting agency supplying the information does not make the decision to take adverse action and cannot give specific reasons for the adverse action; only Bethany Retirement Living makes such a decision.

I further authorize Bethany Retirement Living, if I am accepted to volunteer, to request a background report about me for volunteer- related purposes at any time during the course of my volunteering opportunity to the extent allowed by law. I agree that this Disclosure and Release will be valid now or in the future, in original, faxed, copied or electronic form.