National Child Protection Act/Volunteers for Children Act Waiver and Consent Form

The criminal history record checks performed under the National Child Protection Act (NCPA), as amended by the Volunteers for Children Act (VCA) and Child Protection Improvements Act, and Minnesota Statutes §§299C.60-64 will determine if you, as a covered individual (current or prospective employee, volunteer, or owner/operator), have been convicted of crimes that bear upon your fitness to have access and/or responsibility for the safety and well-being of children, the elderly, or individuals with disabilities (persons with a mental or physical impairment who require assistance to perform one or more daily living tasks). Pursuant to the NCPA/VCA and MnSA §§299C.60-64, this form must be completed and signed by any current or prospective employee, volunteer, or owner/operator for whom criminal history records are requested by a Qualified Entity (QE). QEs are business or organizations, whether public, private, for-profit or voluntary, that provide care (including treatment, education, training, instruction, supervision, recreation) or care placement services, or license/certify others who provide care to children, the elderly, or individuals with disabilities.

Please provide the following information:

Qualified Entity Name: KM Youth Fishing Team              Qualified Entity Address: 903 12th Ave NW, Kasson, MN 55944  

Qualified Entity Phone: 507-269-3021             Qualified Entity Account/ORI: T072693021  

Position Applied for: ___________________________________

I am a current or prospective (check one): ___ Employee ___ Volunteer ___ Owner/Operator

I have been convicted of or pled guilty to a crime. ____ No ____ Yes

If yes, please provide a description of the crime and the particulars of the conviction in the space below.

___________________________________________________________________________________________

___________________________________________________________________________________________

I hereby authorize the requesting QE to submit a set of my fingerprints to the Minnesota Bureau of Criminal Apprehension (BCA) and Federal Bureau of Investigation (FBI) for the purpose of accessing and reviewing state and national criminal history records that may pertain to me to determine my suitability.  I further understand the following:

• My fingerprints will be used to check the criminal history records of the BCA and the FBI;

• I can receive a copy of the state criminal history record from the BCA and a national criminal history record from the FBI pursuant to Title 28, Code of Federal Regulations, §16.30-16.34;

• I am entitled to challenge the accuracy and completeness of any information contained in such records;

• The QE may choose to deny me access to persons to whom the QE provides care until the criminal history record check is completed; and

• I may obtain a prompt determination as to the validity of my challenge before a final decision is made.

By signing this waiver, it is my intent to authorize the dissemination of any state or national criminal history record which may pertain to me, to the requesting QE, or in the case of a private entity, a notification as to whether I am fit for the aforementioned position. I have read and understood the foregoing and the information provided is true and accurate to the best of my knowledge and belief.

*Printed Name: ___________________________________   *Date of Birth______________________________

Other name(s) used: __________________________________________________________________________

*Signature________________________________________   Date_____________________________