CRIMINAL RECORD RELEASE AUTHORIZATION FORM

Name, Last

First

Middle Initial

Address

City

County

State

If at current address less than 5 years, give previous address

Address

City

County

State

Driver's License #

State

Expiration Date

Social Security #

Home Group

City

District

These questions are requested to assure that you are an Al-Anon member qualified to meet the WSO State requirements for working

with teens. An AA member who is not an Al-Anon member may not serve as a Sponsor.

Please check YES or NO and INITIAL each item.  Sign and Date the form below.

STATEMENT

YES

NO

INITIAL

I am at least 21 years old.

I have been active in my Al-Anon program for at least 2 years, excluding time in Alateen.

I make a minimun of 1 year commitment to Sponsorship.

I certify that I have never been charged with and/or convicted of any offense involving sexual misconduct

or physical violence against children.

I agree not to have overt or covert sexual interaction (whether consensual or not) with an Alateen

member, including but not limited to 1) touching a teen inappropriately 2) dating a teen who is an Alateen

member 3) holding or hugging in an inappropriate manner

I agree to perform my Alateen sponsoring responsibility within my district and area guidelines for

Alateen Sponsors.

I understand that as an Alateen Sponsor, my primary goal is to help the Alateen members follow the

Al-Anon program.  Should anything interfere with this objective, (i.e. accusations, controversy, threats

of personal harm, etc.), and if asked to resign my position as a Group Sponsor, I will consider the safety

of the teens to be paramount and will resign.  Even if I feel totally blameless, I understand my removal from

the situation will protect the Alateen members and preserve the unity of the fellowship as well.  I

understand that stepping away from sponsoring an Alateen group is not an admission of Guilt.

I understand that any information obtained will be securely stored and protected by the private security

agency and that the Al-Anon/Alateen Area 54 Area Alateen Coordinator will only be informed of

satisfactory/unsatisfactory background check results.

I have read, understand and agree that the items checked and initialed above are correct.  I agree to

promptly notify the Area Alateen Coordinator when any of these criteria have changed.

As a condition of serving as an Alateen Sponsor to the best of my ability, I give permission to the West Texas Area and its authorized

private security agency to conduct a background investigation on me, which may include a review of sex offender registries, child abuse

and criminal history records.  I agree to hold harmless from liability, the Alateen Group, West Texas AWSC members, AFG Headquarters, Inc.,

employees and volunteers of these organizations.  I understand that these organizations and persons are not under any obligation to appoint

me as an Alateen Sponsor.

Signed

Date

Print Name

Please return this completed form to the WTA Designated Administrator.  This information is confidential and will be

used and distributed only in accordance with applicable law.