Bruce Hennings, Director, Service Leadership Programs 550 Fesler Street, Suite G‐3 • El Cajon, CA 92020 Office: 510‐562‐7055 Fax: 510‐562‐0688 E‐Mail: firstname.lastname@example.org
BACKGROUND CHECK AUTHORIZATION
The Cal-Nev-Ha District of Kiwanis International is committed to the highest standards of practice to ensure the safety and security of the young people engaged in its programs. All non-Key Club members over the age of 18 attending the CaliNev-Ha District Convention must have a limited criminal history background check. Please complete and sign this form and send to the Kiwanis District Office by March 24, 2008. To expedite the process, fax
the form to the Cal-Nev-Ha Confidential Service Leadership Programs fax line at: (510)-562-0688, and then mail the original to the address below.
As an adult who will be present at the Cali-Nev-Ha Key Club Convention, I authorize any law enforcement agency to supply any and all pertinent information and release same from any liability resulting from submitting/releasing such information.
Full Name Social Security Number Date of Birth __ _/_ _____/________
_______ Current Street Address City State/Province Zip/Postal Code (Please use back of form if more space is needed.) Country(ies) of Residence in the last 10 years (Please use back of form if more space is needed.) Signature Date This form must be sent by postal mail to the address below. Cal-Nev-Ha Kiwanis District Office Key Club Background Checks 550 Fesler Street, Suite G-3 El Cajon, CA 92020
OFFICE USE ONLY Date received: Notes: Date processed:
State(s)/Province(s) of Residence in the last 10 years