ALL CAMP VOLUNTEERS & STAFF MUST COMPLETE THE REQUEST FOR CRIMINAL RECORD CHECK FORM! Kamp Keirsey pays for the background check. Do not send money.

Complete the top section containing your name, address, etc.  Your signature and date is required under the ATTENTION YOUTH SERVICE PROVIDERS section. 

Kamp staff will complete the REQUESTING ENTITY section as well as the bottom section, PROCESSING FEE SCHEDULE AND METHOD OF PAYMENT.  Leave these sections blank. Do not send money.

Send forms to Kamp Keirsey,  10002 NW Route J, Amsterdam, MO 64723.

If you have a scanner available,  you may scan and email the form to: David Hertzog at