WHEATLAND MUSIC ORGANIZATION …

                           WHEATLAND MUSIC ORGANIZATION
                                      VOLUNTEER INFORMATION

Legal Name: Last: _______________________ First: ___________________ Middle Initial _______

Address: ___________________________________________________________ Gender: M F (circle one)

City: ________________________          State:_____    Zip Code:______________       Race: _______________

Phone:    (home): ______ / ___________________               (work): ______ / ___________________

Email: ________________________________________________________________________

Special licenses or skills: __________________________________________________________________

Have you: volunteered for WMO before? __________ been convicted of a criminal offense? __________

Date of Birth: _______________ Consent valid for: ___one year from date below ____future years
                                (failure to mark one will automatically become `future years')


                                BACKGROUND CHECK PERMISSION

Please Read Before Signing:

I have been provided a copy of WMO's Background Clearance Policy. I understand that a background check
will be conducted for conviction information only, and that the existence of a criminal record will not
necessarily affect my volunteer status. Automatic review of status will commence upon the finding of any
criminal history within the preceding ten (10) years, of any form of violence, assault, domestic violence, or
abuse against children.

   ·     I understand that I am giving my permission for the Wheatland Music Organization to institute a
         background check on me.
   ·     I understand that the results of this check will be held in the strictest confidence, and access to this
         information will be limited within the Wheatland Music Organization.
   ·     I understand that I have the right to revoke this consent, in writing, at any time.
   ·     I hereby release the Wheatland Music Organization, its' employees, agents, and contractors, from any
         and all liability whatsoever, arising out of this request to consent to a criminal background check, and
         any decisions made concerning my application to be a volunteer, based on the results of this background
         check


         ____________________________________________________                    ___________________
             Signature (applicant or parent/guardian if under 18)                       Date

mail to:                                                fax to:
        Wheatland Music Organization                              989-967-8562
        PO Box 22
        Remus, MI 49340