HTML Preview Employment Check Authorization Form page number 1.
YMCA OF HORNELL NEW YORK, INC.
18 Center Street
Hornell, New York 14843
P 607 324 5520
Employee and Volunteer Background Check Authorization
Please complete all sections of this form. All information collected on this form is confidential.
Attach a copy of photo identification (driver’s license, passport, etc.).
Name_________________________________________________________________________________________________________________________
Last First Middle Maiden
Birth Date __________/_____________/____________ S.S.N.___________-__________-_______________
Present Address_____________________________________________________________________ From:____________ To:_____________
Street City, State Zip Code (Month/Day/Year)
Past Address_________________________________________________________________________ From:____________ To:_____________
Street City, State Zip Code (Month/Day/Year)
Telephone___________________________________________________________________________________________________________________
Cell Home Work
Driver’s License____________________________________________________________________________________________________________
Number State
Have you ever been convicted, or entered a plea of guilty or no contest, to a crime? Yes No
If yes, please provide the nature of the crime, date, and conviction information.
(A conviction is not necessarily a bar to employment)
________________________________________________________________________________________________________________________________
Notice to All Applicants: The YMCA enforces its policies and practices to prevent child abuse.
Allegations or suspicions of child abuse are taken very seriously at the YMCA and will be reported
to the proper authorities for investigation. We have abuse reporting procedures, there are
unscheduled visits from supervisors, we have an open door for parents, and we have a code of
conduct for staff. We minimize opportunities for abuse to occur and we talk with children about
personal safety and touching limits. We also screen carefully to prevent abusers from being hired
and we provide child abuse prevention training to staff. I hereby grant the YMCA OF HORNELL NEW
YORK permission to conduct a background check.
Applicant Signature______________________________________________________ Date_________/__________/__________
YMCA USE ONLY
Background check completed by______________________________________ Date_________/__________/__________
Attach background reports and return to Mark Morrissey, Executive Director