2013 Fairplex Volunteer Application - Home of the L.A. County Fair

Please read carefully before completing this application. This organization does not discriminate in the recruitment and placement of volunteers on the basis of race, color, religion, national origin, sex, marital status and disability, age or veteran status. No questions on this application are intended to secure information to be used in a discriminatory manner. Your completed application will be reviewed carefully but its receipt does not imply that you will be chosen as a volunteer. ALL VOLUNTEER POSITIONS REQUIRE A BACKGROUND CHECK.

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* 1. Please fill out the information below

First Name *

Last Name *

Current Address *

City/Town *

State *

ZIP *

Email Address

Cell/Preferred Phone Number *

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* 2. Please fill out the following information

Alternate Phone

Date of Birth ex: 01/01/2013 (must be at least 16 years of age by August 30) *

How many years have you volunteered at the L.A. County Fair (list 0 if you are a new applicant) *

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* 3. If you were referred to the program by a current volunteer, please list his/her name

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* 4. Have you ever been convicted of a felony or misdemeanor?

Yes

If yes, please describe:

(A conviction does not mean you will not be offered a volunteer position. What you were convicted of, the circumstances surrounding the conviction and how long ago the conviction occurred are important considerations in determining your eligibility. Give all the facts so that a fair decision can be made.)

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* 5. Emergency Information (please note that hospitals ONLY allow next of kin to make decisions on your behalf)

Emergency Contact Name *

Relationship *

Contact Phone Number *

Alternate Phone Number

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* 6. Any medical problems, allergies, etc. that we should be aware of in the event of an emergency.

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* 7. Exposure/Environmental Conditions

	Yes	No
Ability to lift 25 lbs. or more	Ability to lift 25 lbs. or more Yes	Ability to lift 25 lbs. or more No
Interacting with children/young adults	Interacting with children/young adults Yes	Interacting with children/young adults No
Standing for periods in excess of three hours	Standing for periods in excess of three hours Yes	Standing for periods in excess of three hours No
Volunteering indoors only	Volunteering indoors only Yes	Volunteering indoors only No
Volunteering outdoors (direct sunlight)	Volunteering outdoors (direct sunlight) Yes	Volunteering outdoors (direct sunlight) No
Volunteering outdoors (shaded area)	Volunteering outdoors (shaded area) Yes	Volunteering outdoors (shaded area) No
Walking distances greater than a mile	Walking distances greater than a mile Yes	Walking distances greater than a mile No

BACKGROUND DISCLOSURE AND AUTHORIZATION FORM
The Los Angeles County Fair Association (the Company) will procure a consumer report and/or investigative consumer report on you in connection with your volunteer application (including independent contractor assignments, as applicable). These background reports may be obtained at any time after receipt of your authorization and, if you are engaged by the Company, throughout your volunteer participation.
Intelius Screening Solutions LLC, a consumer reporting agency, will obtain the report for the Company. Intelius Screening Solutions is located at 19800 North Creek Parkway, Suite 200, Bothell, WA 98011, and can be reached at (866) 338-6739.
The report may contain information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include, but are not limited to: credit reports, social security number verification, criminal records checks, public court records checks, driving records checks, educational records checks, verification of employment positions held, personal and professional references checks, and licensing and certification checks. The information contained in the report will be obtained from private and/or public record sources, including sources identified by you in your job application or through interviews or correspondence with your past or present coworkers, neighbors, friends, associates, current or former employers, educational institutions or other acquaintances.

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* 8. Background Disclosure and Authorization Information (This information is solely being collected to conduct the background screening. It will not be used for any other purpose).

First Name

Full Middle Name

Last Name

Current Address

City

State

Zip

Date of Birth (ex: 01/01/2013)

Social Security Number

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* 9. Licence Information

Driver's Licence #

State of Issue

Additional Names Known As

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* 10. If you volunteered in 2012, have you lived in a different county since that time?

Yes

Additional State Law Notices
If you are a California, Maine, New York, or Washington state applicant, employee, or contractor, please also note:
CALIFORNIA: Pursuant to section 1786.22 of the California Civil Code, you may contact Intelius Screening Solutions during normal business hours (9am to 5pm PST, Monday through Friday) to obtain and review all information in your file. You may obtain such information by appearing in person at Intelius Screening Solutions’ offices, during normal business hours and upon reasonable notice, and upon submitting proper identification and paying the costs duplication services. You may be accompanied by one other person, provided that person furnishes proper identification. You may also obtain a copy of your file by certified mail, if you have previously provided identification in a written request that your file be sent to you or a third party identified by you. You may also obtain a summary of your file by telephone, upon providing proper identification. Intelius Screening Solutions has trained personnel available to explain your file to you, including any coded information.
CALIFORNIA (En Español): De acuerdo con el artículo 1786.22 del Código Civil, se puede llamar a Intelius Screening Solutions por los horarios normales de trabajo (9 de la mañana a 5 de la tarde, tiempo del pacífico, lunes a viernes) para sacar y examinar su archivo privado en detalle. Para conseguir una copia de su archivo privado, se puede hacer una visita en persona a la oficina de Intelius Screening Solutions por los horarios normales de trabajo, al darnos aviso razonable, al presentarnos de identificación apropriada, y al pagarnos las cuestas de duplicación. Otra persona puede accompañarle con tal que también se traiga identificación apropriada. Se puede pedirnos que le mandamos por correo certificado una copia de su archivo privado con tal que hayamos recibido una solicitud escrita que se lo mandemos una copia de su archivo privado a Usted o tal tercer partido que esté identificado por Usted. También se puede pedir por teléfono un resumen de su archivo privado, al presentarnos identificación apropriada. Empleamos trajabadores cualificados, a quienes están disponibles para explicárselo el contenido de su archivo privado con más detalles, incluso algunos datos cifrados.
MAINE: You have the right, upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the Company, within five business days of our receipt of your request, the name, address, and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such agencies copies of any such reports.
NEW YORK: At the time you consent to your employer obtaining a report you are entitled to receive a copy of Article 23-A of New York Correction Law. Do not sign your consent until you receive a copy of that law.
WASHINGTON: If the Company requests and investigative consumer report, you have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation requested by the Company. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

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* 11. Provided to you with this authorization is a Summary of Your Rights Under the Fair Credit Reporting Act in a form prescribed by the Federal Trade Commission. Please do not sign this authorization until you have received this summary. You may request more information about the nature and scope of the background report by contacting the Company.

California, Minnesota, and Oklahoma applicants only: check this box if you request a copy of the report ordered on you.

BACKGROUND SCREENING AUTHORIZATION
I have carefully read and understand this disclosure and authorization form and I have received a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act” provided with this form. I have had the opportunity to review my rights. By my signature below, I consent to the preparation of background reports by Intelius Screening Solutions LLC, and to the release of such reports to the Company and its designated representatives for the purpose of assisting the Company in making a determination as to my eligibility for employment, promotion, retention, contract assignment or for other lawful purposes.
I understand that, to the extent allowed by law, information contained in my job application or otherwise disclosed to the Company by me before or during my employment or contract assignment, if any, may be utilized for the purpose of obtaining such consumer reports and/or investigative consumer reports about me. I understand that nothing herein shall be construed as an offer of employment or contract for services.
I hereby authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal/state/local), motor vehicle record agencies, my past or present employers, the military, and other individuals or sources to furnish any and all information on me that is requested by the consumer reporting agency.

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* 12. By my signature (including electronic) below, I certify the information provided on and in connection with this form is true, accurate, and complete. I agree that this form in original, faxed, photocopied or electronic form will be valid for any background reports that may be requested by or on behalf of the Company.

Dated

Signature