Date Format: MM slash DD slash YYYY
Education and Employment History
Please list complete information for one reference (not related to you) who has knowledge of your qualifications for this position. A reference form will be sent to the individuals listed below.
AuSM is seeking staff for our 2021 Summer Recreation programs. Each session meets weekly for five consecutive weeks at various locations around the Twin Cities area. Each session has a morning and and afternoon time slot that serves slightly different age groups.
AuSM is adhering to the State of Minnesota’s Covid-19 safety guidelines and working to create a schedule that allows our staff time to monitor their health and inform AuSM of any potential symptoms. We appreciate your interest in working with AuSM this summer and are grateful for your commitment to keeping our community safe.
Please contact Mike Pucci (firstname.lastname@example.org) with any questions.
- An Equal Opportunity Employer
AuSM is an equal opportunity employer, and we do not and will not discriminate on the basis of race, religion, national origin, sex, age, handicap, marital status, or status as a disabled veteran. Information provided on this application will not be used for any discriminatory purpose. Your complete application form will be valid for the duration of the application calendar year. You may submit a new application at any time and are responsible to notify AuSM of any changes of address or other contact information.
All information provided herein is considered confidential and will not be shared with any third party without consent.
Provide All Information Requested
I understand that all information provided herein will be subject to a Background Check, check of references and employer, and that my employment may be contingent upon receipt of an alien registration number, verification of birth, and any other pertinent information bearing upon my employment.
By typing your name on the signature line, you acknowledge it to be binding in substitution for your handwritten signature and that it indicates your approval of the information contained in this document.
Child Protection Background Check Act Form
- Because the position for which you are applying will require you to provide care, treatment, education, training, instruction, or recreation to children, the Autism Society of Minnesota will request the Bureau of Criminal Apprehension (BCA) to perform a criminal background check on you under Minnesota Statutes Chapter 299C.62.
Background check crimes under Minnesota Statutes Chapter 299C.62
Felony Level Assault Kidnapping
Criminal Sexual Conduct Manslaughter
Any Assault Crime Against a Minor
Any of the following Child Abuse Crimes committed against Minor victim, constituting a violation of Minnesota Statutes Section
609.185,(5) Murder in the 1st Degree
609.221 Assault in the 1st Degree
609.222 Assault in the 2nd Degree
609.223 Assault in the 3rd Degree
609.224 Assault in the 5th Degree
609.2242 Domestic Assault
609.322 Solicitation, Inducement and Promotion of Prostitution
609.324 Other prohibited acts of Prostitution
609.342 Criminal Sexual Conduct in the 1st Degree
609.343Criminal Sexual Conduct in the 2nd Degree
609.344 Criminal Sexual Conduct in the 3rd Degree
609.345 Criminal Sexual Conduct in the 4th Degree
609.352 Solicitation of Children to Engage in Sexual
609.377 Malicious Punishment of a Child
609.378 Neglect or Endangerment of a Child
152.021, subd.1,(4) Controlled Substance Crime in 1st Degree
152.022, subd.1,(5) or (6) Controlled Substance Crime in 2nd Degree
152.023, subd.1,(3) or (4) Controlled Substance Crime in 3rd Degree
152.023, subd.2,(4) or (6) Controlled Substance Crime in 3rd Degree
152.024, subd.1,(2), (3) or (4) Controlled Substance Crime in 4th Degree
As the subject of a Child Protection background check, your rights include:
• to be informed that the Autism Society of Minnesota will request this check for becoming or continuing as an employee or volunteer, and to determine whether you have been convicted of any of the above specified crimes,
• to be informed of the BCA's response and obtain a copy of the report from the Autism Society of Minnesota,
• to obtain from the BCA any record that forms the basis for the report, and
• to challenge the accuracy and completeness of any information contained in the report (procedures set forth in MN Statutes §13.04 and Title 28, CFR, Section 16.34), and
• to be informed whether the Autism Society of Minnesota has denied your application because of the BCA's response and not to be required directly or indirectly to pay the cost of the background check.
This release is valid for one year from the date of my signature. *By typing your name on the signature lines in this document, you acknowledge it to be binding in substitution for your handwritten signature and that it indicates your approval of the information contained in this document.
1. Records obtained under the Minnesota Statutes Chapter 299C.62 may be used solely for the purpose requested and cannot be disseminated outside the receiving departments, related agencies, or other authorized entities.
2. Your fingerprints may be used to check the criminal history records of the FBI.
*By typing your name on the signature lines in this document, you acknowledge it to be binding in substitution for your handwritten signature and that it indicates your approval of the information contained in this document.
Informed Consent Release of Predatory Offender Registration Data
Because the position for which you are applying will require you to provide care, treatment, education training, instruction, or recreation to children, the Autism Society of Minnesota will request the Bureau of Criminal Apprehension to perform a POR check on you in conjunction with a criminal history check pursuant to Minnesota Statues §299C.62.
I hereby authorize and grant my informed consent to the Minnesota Bureau of Criminal Apprehension to release to the Autism Society of Minnesota any information contained about me in the Minnesota Predatory Offender Registry, including, but not limited to, information related to offenses which may have occurred when I was a juvenile.
I hereby release the Minnesota Bureau of Criminal Apprehension and the Autism Society of Minnesota from any and all actions and causes of action, of any kind and nature whatsoever, past, present and future, arising out of the release of information obtained with this consent.
This authorization shall be valid for a period of twelve (12) months from the date of signature.
*By typing your name in the above boxes in this document, you acknowledge it to be binding in substitution for your handwritten signature and that it indicates your approval of the information contained in this document.