Sex Offender Supervision Chaperone Authorization to Release Information

Offender’s Information
Offender’s name: IDOC#:

Proposed Chaperone’s Statement of Understanding and Authorization

As an applicant for chaperone with the Idaho Department of Correction (IDOC), I understand that I am providing personal history information to determine my qualifications and suitability
as chaperone with the IDOC.

I understand that I am voluntarily providing personal information such as my name, race, height, weight, gender, date of birth, place of birth, driver’s license number, and social security
number to assist in conducting a background check. By not providing the required information, I am voluntarily suspending, terminating or forfeiting my opportunity as chaperone.

I hereby authorize any representative of the IDOC bearing this release, or copy of this release, within one-year of its date, to obtain any or all records and information concerning
myself regardless of whether the records and information are of a confidential nature. The release of files, records, and information may include, but not be limited to, arrest records
and criminal files.

I understand that any information obtained in the background, records, or information check will be considered in determining my qualifications and suitability as a chaperone with IDOC.
I also understand that any person, partnership, association, organization, or government agency (including their employees who provide information concerning me) will not be liable for
providing accurate records or information.

Therefore, I release all persons and parties from all claims, damages and liabilities that may result from providing the information requested by an authorized agent from IDOC.

Social Security Number:

Current Home Address:
Street City State Zip
Current Phone Numbers:
Home Cell Other

Proposed Chaperone’s Printed Name

Proposed Chaperone’s Signature Date

Witnesses (as applicable)

PPO’s Printed Name

PPO’s Signature Date

Treatment Provider’s Printed Name

Treatment Provider’s Signature Date