I, ________________________________________, hereby authorize the Catholic Diocese of Dodge City and/or its agents, affiliates, parishes and representatives, to make an independent investigation of my background, references, past employment, education, criminal or police records, child or adult abuse and neglect registries, including those maintained by both public and private organizations and all public records for the purpose of obtaining information which may be material to my qualifications as a volunteer with the Catholic Diocese of Dodge City, its parishes or affiliates.

I release the Catholic Diocese of Dodge City and/or its agents, affiliates, parishes and representatives as well as any person or entity which provides information pursuant to this authorization, from any and all liabilities, claims, or law suits arising out of or in any manner related to information obtained from any and all of the above referenced sources used.

The following is my true and complete legal name and all information contained herein is true to the best of my knowledge:

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Volunteer Name and Signature

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Street Address, City, State and Zip Code

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Date

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Social Security Number*

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Date of Birth*