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Washtenaw County Sheriff's Office
Application for Internship or Volunteer Position

Applying For:*
Name*
Address*
Gender Identity*
Date of Birth*
Is an internship required for your current academic program?*
Expected Graduation Date*
If none, write "N/A."
Ex: Bob Jones (Spouse)

Employment

Address*
MM / DD / YYYY
MM / DD / YYYY

Release of Liability / Release of Information

Release of Liability

I acknowledge there are risks associated with participating in this activity, including but not limited to those associated with natural phenomenon, accident, my own actions or actions of others. I understand that these risks may result in serious illness, injury or death, and I hereby accept and assume, all such risks. In consideration for being allowed to participate in this activity, which I do freely and voluntarily, for myself, my executors, administrators, heirs, next of kin, successors, and assigns, I agree to:

  1. Waive, release, hold harmless, and discharge from any and all liability Washtenaw County, Washtenaw County Sheriff’s Office, Washtenaw County Sheriff, and their appointed officials, employees, students, agents, and volunteers, and any other volunteers not associated with Washtenaw County for any death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter occur during the participation in this activity.
  2. Hold harmless Washtenaw County, Washtenaw County Sheriff’s Office, Washtenaw County Sheriff, and their appointed officials, employees, students, agents, and volunteers, and any other volunteers not associated with Washtenaw County from any and all liabilities or claims made by other individuals or entities as a result of or relating to my participation in this activity.
  3. Follow all verbal and written directives of the Sheriff and his staff, and keep confidential any proprietary or privileged information gained through connection with the Sheriff’s Office. I shall not make statements to the news media concerning the Sheriff’s Office operations or investigations other than with expressed consent. I shall not make any photographic, vocal, or video recordings for personal use while engaged in my duties with the Sheriff’s Office.

I furthermore understand the organizing or sponsoring groups are not and will not be responsible for any medical costs that may be incurred. I authorize emergency medical services if required, if I am unable to give permission or my emergency contacts cannot be reached.

I understand and agree to the statements above.

Release of Information

I authorize the release, review, and full disclosure of all records, or any part thereof, concerning myself to any authorized agent of the Washtenaw County Sheriff’s Office whether the records are public, private, or confidential in nature.

The purpose of this authorization is to give my consent for full and complete disclosure of the listed records:

  • Educational Institutions
  • Utilities companies, cable / satellite entertainment,  and telephone service providers   
  • Financial or credit institutions, to include records for any depository or savings or checking accounts
  • Commercial or retail credit agencies, to include credit reports and ratings
  • Medical, psychological, psychiatric and substance abuse reports of consultations, treatments and evaluations at or by any hospital, clinic, private practitioner, and the US Veterans Administration
  • Employment or pre-employment records, to include salary records, background reports, polygraph examination reports and polygraph examination questions, pre-employment and promotional examination results, efficiency ratings, disciplinary actions, complaints, grievances or internal affairs investigation reports filed by or against me
  • Real and personal property tax statement and records, as well as other financial statements or records wherever filed
  • Records of criminal complaints, arrests, arrest photographs, trials and convictions for alleged or actual law violations, including criminal, traffic records and department of motor vehicle records
  • Records of civil complaints, including Child Protective Services, made by or against me, wherever located, to include the records and re-collections of attorneys at law and other counsel, whether representing me or another person in any case in which I have ever been party to or an interest

The reason for this authorization is to provide full and free access to the background and history of my personal life for the specific purpose of conducting a background investigation that may provide pertinent information for the Washtenaw County Sheriff’s Office to consider in determining my suitability for employment.

In the event my application is disapproved, the sources of any confidential information will not be revealed to me. I agree to indemnify and hold harmless the person to whom this request is presented, as well as his or her agents and employees, from and against all claims for damages, losses or expenses, to include reasonable attorney’s fees arising out of or by the reason of complying with this request.

This release form, and any copy of this release form, even though the said copy does not contain original writing of my signature, will be valid and should be honored for a period of one year from the date of my signature.

By clicking on “submit” I hereby authorize my former employers as indicated above, to provide Washtenaw County any information pertaining to my employment. I also specifically waive the written notice requirement of Section 67 of Public Act 397 of 1978 pertaining to disciplinary reports, letters of reprimand or other disciplinary actions.

In addition, by clicking on “submit”, I certify and acknowledge the following: The information is correct to the best of my knowledge and that I have attached all information on my qualifications for this position. I understand any false statement or answer may be grounds for dismissal, if I should be employed by the County. I further understand that if I am offered employment, references will be obtained from previous employers; a physical which includes drug testing for safety sensitive jobs (at County expense) may be required; proof of educational attainment must be submitted; and, if any driving will be done for County purposes in a County vehicle or my own vehicle, a check of my driving record will be obtained. For specific positions, extensive background checks may be required.

Further, by clicking on “submit”, I agree that I will sign a written version of this disclaimer if I am ultimately hired by the County.

Release of Information

This is to authorize you to furnish the Washtenaw County Sheriff’s Office (WCSO), or any representative thereof, any and all information, which they may request regarding the records of the above-named individual. These records are including, but not limited to, school records, employment documents including disciplinary histories, military records, credit information, driving record, criminal records/history, and other public records from all persons, businesses, schools, government agencies, social organizations or other organizations or institutions which release such information. This also authorizes the WCSO to make whatever inquiries the WCSO deems appropriate to determine your suitability to participate as a Volunteer / Intern / Citizen’s Police Academy participant.  The information you are providing below is needed to gather this information, but the information obtained will be held in confidence as provided by law. I understand that I may periodically be run in LEIN (Law Enforcement Information Network)and/or other databases to verify my driver’s license status and confirm I have no wants/warrants, criminal history, or negative law enforcement contacts. 

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