FCS Volunteer Waiver and Consent

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

The fingerprint-based criminal history record checks performed under the National Child Protection Act (NCPA), as amended by the Volunteers for Children Act (VCA), will determine if you, as a care provider (current or prospective employee, volunteer, contractor/vendor, or owner/operator), have been convicted of crimes that bear upon your fitness to be responsible 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, this form must be completed and signed by every current or prospective provider for whom criminal history records are requested by a Qualified Entity or Authorized Agency for applicants who provide care, treatment, education, training, instruction, supervision, recreation, care placement services, or license/certify others who provide care to vulnerable populations (children, the elderly, or individuals with disabilities).

1.	I am a current or prospective (check one):*
	Employee    Volunteer    Contractor/Vendor    Chaperone    Coach    School Governance Council (SGC)

PLEASE READ CAREFULLY I hereby authorize the submitting of my fingerprints through an authorized agency to the Georgia Bureau of Investigation (GBI) and Federal Bureau of Investigation (FBI) for the purpose of accessing and reviewing state and national criminal history records that may pertain to me. I further understand the following: My fingerprints will be used to check the criminal history records of the GBI and the FBI; I can receive a state criminal history record from the GBI 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 Qualified Entity/Authorized Agency may choose to deny me unsupervised access to persons to whom they provide 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.

2.	Enter the School Name or Contracting Agency*

3.	Enter your FULL NAME as it appears on your state issued ID or drivers license*

4.	Enter your Street Address, City, State & Zip Code*

5.	Enter your Phone Number

6.	Enter your Date of Birth*

7.	By checking the "I AGREE" box, I authorize the dissemination of any state or national criminal history record that may pertain to me, to the requesting authorized agency. I have read and understood the foregoing and the information provided is true and accurate to the best of my knowledge and belief. *
	I AGREE