The information contained in this application is correct to the best of my knowledge. I authorize any references listed in this application to relay information they may have regarding my character and fitness for work on behalf of children. I also give permission to check my criminal history with the Michigan State Police. I release all such references from liability for any damage that may result from furnishing such evaluations to you, and I waive any right that I have to inspect references provided on my behalf.
Applicant signature (please sign your name in the box below to confirm the above statement is true):
