��ࡱ� > �� 9 > ���� 8 �������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� ] �� � bjbj���� 4. ��!b��!b� �� �� �� � R R � � � � � ���� � � � � � , � P . * * * * * � � � � � � � $ ~ � 4 � � � � � � � � � * * � [ [ [ � " � * � * � [ � � [ [ [ * ���� ���A��� ���� j [ � 0 P [ � u � � [ � � [ ` " ' [ ? S � � � � ^ P � � � � ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� � R B � : MSU Extension Background Check Form for 18-, 19- and 20-Year-Olds This form is to be completed for any youth aged 18, 19 or 20 at the time of the event who is planning to attend an overnight event as a participant.依据密歇根4-H青年方案青年-Adult夜校策略进行至少一次参考检验和犯罪历史检验BOB体育保护隐私 密歇根州立大学扩展教程请返回附密信封中填全表____________________________________________________________________________ Last Name First Name Middle Initial _____________________________________________________________________________ Other Last Name Other First Name Other Middle Initial Sex: Male Female Date of birth: __________________________________ Month Date Year Have you ever been convicted of a felony or a misdemeanor?No Yes If Yes, Please explain: ___________________________________________________________________________ Please list two references such as employers or teachers.不列亲戚____________________________________________________________________________ Name Address City ______________________________________________________________________________ Phone Number(s) ____________________________________________________________________________ Name Address City ______________________________________________________________________________ Phone Number(s) I give my permission for the above-named references to release information about me and for my criminal history to be verified.BOB体育密歇根州立大学扩展许可 向州警和本地警 以及我居住过的其他州BOB体育_______________________________________ ____________________________ Signature Date Michigan State University Extension programs and materials are open to all without regard to race, color, national origin, gender, gender identity, religion, age, height, weight, disability, political beliefs, sexual orientation, marital status or family status or veteran status.MSU Extension Background Check Documentation For 18-, 19- and 20-Year-Olds Criminal History Check: Findings, date conducted, and staff member completing check: ____________________ ________________________________________________________________________ Reference Check 1: Name of reference: ________________________________________________________ How long has reference known person and in what capacity: _______________________ ________________________________________________________________________ Comments about person�s responsibility, trustworthiness, people skills, strengths, etc.: ________________________________________________________________________ ________________________________________________________________________ Concerns about having this person interact with younger youth: ____________________ ________________________________________________________________________ Date reference checked and staff member conducting check: _______________________ Reference Check 2 (optional): Name of reference: ________________________________________________________ How long has reference known person and in what capacity: _______________________ ________________________________________________________________________ Comments about person�s responsibility, trustworthiness, people skills, strengths, etc.: ________________________________________________________________________ ________________________________________________________________________ Concerns about having this person interact with younger youth: ____________________ ________________________________________________________________________ Date reference checked and staff member conducting check: _______________________ ( A B C v w y z | } � � � � � � # b � � � 7 9 O m ������úîîââ��ÖÊ�~sokgk\Q h�j<