Consent for Release of Information
I certify that the answers given in this Questionnaire are true and complete to the best of my knowledge. I authorize Cornerstone and its designated agents and representatives to investigate all statements in this Questionnaire and conduct a comprehensive review of my background causing an investigative report to be generated for volunteer purposes.
I understand that the scope of the investigative report may include but is not limited to the following areas: verification of social security number, current residence, and civil and criminal history records from any criminal justice agency in any or all federal, state, county, or other jurisdiction.
I freely authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration, law enforcement agencies, all current or past employers and educational institutions) to divulge any and all information, verbal or written, pertaining to me, to Cornerstone Chapel or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.
I hereby release Cornerstone Chapel and all agents officials, representatives, or assigned agencies, and any authorized investigation agency from any and all liability, damages, and claims arising directly or indirectly from this background check.
If appointed, I understand that false and misleading information given in my Questionnaire, or interview(s) may lead to discharge from the safety team.
June 23, 2021
We understand that the information requested in this questionnaire is sensitive. We ask these questions in an effort to protect Cornerstone Chapel, all its attendees, and agents, including you from danger and liability! All information contained in this questionnaire shall be kept confidential and only provided to Cornerstone agents and representatives on an as needed basis. Please answer all questions truthfully and completely.
1. Why do you want to be a part of the Cornerstone Safety and Security Team?
2. What experience do you have in security practices?
3. What is your current medical condition? Are you able to undertake the duties of the Safety and Security Team? On a regular basis this may include walking, standing, and lifting. In emergency situations greater physical exertions may be required.
4. What prescription drugs are you currently taking and what condition do they treat?
5. What over the counter drugs do you take and what condition do they treat?
6. Have you ever taken anti-depressant medications?
7. Have you ever sought spiritual or pastoral counseling? If so, from which church, pastor, or spiritual mentor?
8. Have you ever sought other counseling, including professional therapy or counseling for behavioral concerns, addictive behaviors, or mental disorders?
9. Have you ever been addicted to a substance or abused a substance?
10.Have you ever been diagnosed with a mental disorder?
11. Have you ever been charged, indicted, or convicted of a crime?
12. Are you prohibited from owning or purchasing a firearm for any reason (Legal, Medical, etc.)?
13. Do you possess a current Virginia concealed carry permit? If not, do you possess a current concealed carry permit from another state recognized by Virginia?
14. What level of proficiency do you have with firearms?
15. What training/certifications do you have with firearms?
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Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent for Release of Information
Agree & Sign