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Boys & Girls Club of Southern Illinois
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Fill out online or download a
printable copy here.
Legal Last Name
Legal First Name
Legal Middle Name
Current Physical Address
City
State
Zip Code
Phone Number
Email
Date of Birth
Gender
Race
Have you ever been arrested or convicted of a felony:
No
Yes
Have you ever been arrested or convicted of a misdemeanor:
No
Yes
If you answered yes to either question above, please provide a brief explanation of offense and date below:
My signature below indicates my understanding that I am being considered for a position of employment or volunteer at the BGCSI and I hereby authorize BGCSI to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Illinois or National Registries. I understand that I may at anytime request in writing a copy of all findings. I further understand that information obtained during the investigation(s) may be used as a basis for the acceptance or denial of appointment or reappointment, as well as termination when appointed to the above position pending completion of my records check investigation. I understand that refusal to supply accurate information and sign this release will result in termination of the appointment process. All information I hereby authorize to be obtained will be confidential.
Print Name
Date
Signature
Please note there is a $15 fee for running your background check. Once you hit Send, you will be redirected to a payment portal to process this. Please use the drop down and select Background Check Fee and Other amount of $15.
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