These forms are based on those developed by the Missing and Exploited Children Comprehensive Action Program and the National School Safety Center under a grant from the Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S. Department of Justice (see Hiring the Right People, Guidelines for the Selection and Screening of Youth-Serving Professionals and Volunteers, 1994). They are included as a starting point for the development of forms by States, agencies, associations, organizations, coalitions, or individuals serving children, the elderly, and individuals with disabilities in need of support.

REGARDING:

Applicant's name:	______________________________
Applicant's current address:	______________________________
Applicant's social security number:	______________________________
Agency contact person:	______________________________
Authorization expiration date:	______________________________

I, the undersigned, authorized and consent to any person, firm, organization, or corporation provided a copy (including photocopy or facsimile copy) of this Authorization to Release Information by the above-stated agency to release and disclose to such agency any and all information or records requested regarding me, including, but not necessarily limited to, my employment records, volunteer experience, military records, criminal information records (if any), and background. I have authorized this information to be released, either in writing or via telephone, in connection with my application for employment or to be a volunteer at the agency.

Any person, firm, organization, or corporation providing information or records in accordance with this authorization is released from any and all claims or liability for compliance. Such information will be held in confidence in accord-ance with agency guidelines.

This authorization expires on the date stated above.

___________________________________ Signature of Prospective Employee	__________ Date
___________________________________ Witness to Signature	__________ Date

OJJDP Summary: Guidelines for the Screening of Persons Working with Children, the Elderly, and Individuals with Disabilities in Need of Support, April 1998