Background Check & DOC Release and Waiver of Liability.docx

South Dakota Department of Corrections Policy Distribution: Public Attachment: DOC Release and Waiver of Liability Please refer to DOC policies 1.1.A.4 / 1.1.D.3 / 1.5.A.6 Relationship w/News Media,/Facility Access & ID Requirements / Community Service Program

Background Check Authorization

Last Name

First Name

MI

Social Security Number

Maiden /Alias Names:

Street Address/P.O. Box

City

Home Telephone Number

Work Telephone Number

Cell Phone Number (optional)

Date of Birth

Driver’s License Number #

State Issuing Driver’s License

I hereby authorize the South Dakota Department of Corrections, or its designated agents and representatives to obtain and review my criminal background. I certify that the information given by me is true, complete and correct, to the best of my knowledge and belief and made in good faith.

The DOC and its designated agents or representatives shall maintain all information received from this authorization in a confidential manner in order to protect my personal information, including, but not limited to, addresses, social security numbers and dates of birth.

Signature of Applicant

Date

Staff Signature

Date

Special Security/Major Signature

Date

Associate Warden/Designee Signature

Date

South Dakota Department of Corrections Policy Distribution: Public Attachment: DOC Access Approval Please refer to DOC policies 1.1.A.4 / 1.1.D.3 / 1.5.A.6 Relationship w/News Media,/Facility Access & ID Requirements / Community Service Program

DOC RELEASE AND WAIVER OF LIABILITY

By my signature below, I acknowledge that I am aware of, appreciate the character of, and voluntarily assume the risks associated with being on DOC property, or participating in DOC activities within the following facilities:

South Dakota State Penitentiary, Jameson Prison Annex, Mike Durfee State Prison, Yankton Community Work Center, Rapid City Community Work Center, South Dakota Women’s Prison or Pierre Community Work Center

I understand that risks associated with such entry and/or participation in DOC activities include, but are not limited to, bodily injury, property loss or damage and death.

By my signature below, on behalf of myself, my heirs, next of kin, successors in interest, assigns, personal representatives, and agents, I hereby:

1. Waive any claim or cause of action against and release from liability the State of South Dakota, its officers, employees, and agents for any liability for injuries to my person or property resulting from such entry and/or participation in DOC activities;

2. Agree to indemnity and hold harmless the State of South Dakota, its officers, employees, and agents for any claims, causes of action, demands, expenses, judgments, fees and costs of whatever kind or character arising from, by reason of, or in connection with my entry to a DOC facility or participation in DOC activities.

I have carefully read this RELEASE AND INDEMNITY AGREEMENT, or had it read to me in a language I fully understand, and I understand all of the terms. I understand I have given up substantial rights by signing this agreement and that it is the intention of the parties that the State and its officers, agents and employees shall not be liable or in any way responsible for injury, damage, liability, loss or expense resulting to me due to accidents, mishaps, misconduct, negligence or injuries. My signature below has been made freely and voluntarily without any inducement, assurance or guarantee being made.