Preview Volunteer Background Check Authorization Form

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VOLUNTEER BACKGROUND CHECK AUTHORIZATION

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Inanefforttocreateasafeenvironmentforyourchildrenandourstaff,wewillrequirebackgroundchecksfor

ourvolunteersworiingdirectlywithchildren.Wehaveinstitutedthispolicyinlightofwhathasbeenhappeningin

schoolsacrossthenation.Workingwithchildrenincludesbutisnotlimitedtobeingachaperone,drivingonfield

trips,roommoms,orteachersaids.Wehavetheabilitytorunabackgroundcheckthroughasystemcalled

ProtectMyMinistry.Pleasereturnthisformtotheschooloffice.Allformswillbeshreddedafterthebackground

ischecked.

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Name:______________________________________________________________________

 (First)   (Middle) (Last)

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FormerName(s)andDatesUsed:________________________________________________

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CurrentAddressSince:_________________________________________________________

 (Mo/Yr) (Street) (City) (Zip/State)

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PreviousAddressFrom:________________________________________________________

 (Mo/Yr) (Street) (City) (Zip/State)

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PreviousAddressFrom:________________________________________________________

 (Mo/Yr) (Street) (City) (Zip/State)

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SocialSecurityNumber:_______________________ TelephoneNumber:__________________

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DriversLicenseNumber/State:__________________ DateofBirth:________________________

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Theinformationcontainedinthisapplicationiscorrecttothebestofmyknowledge.IherebyauthorizeHopeLutheranChurch

andSchoolanditsdesignatedagentsandrepresentativestoconductacomprehensivereviewofmybackgroundcausinga

consumerreportand/oraninvestigativeconsumerreporttobegeneratedforemploymentand/orvolunteerpurposes.I

understandthatthescopeoftheconsumerreport/investigativeconsumerreportmayinclude,butisnotlimitedtothefollowing

areas:verificationofsocialsecuritynumber;currentandpreviousresidences;employmenthistory,educationbackground,

characterreferences;drugtesting,civilandcriminalhistoryrecordsfromanycriminaljusticeagencyinanyorallfederal,state,

countyjurisdictions;drivingrecords,birthrecords,andanyotherpublicrecords.

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Ifurtherauthorizeanyindividual,company,firm,corporation,orpublicagency(includingtheSocialSecurityAdministrationand

lawenforcementagencies)todivulgeanyandallinformation,verbalorwritten,pertainingtome,toHopeLutheranChurchand

Schooloritsagents.Ifurtherauthorizethecompletereleaseofanyrecordsordatapertainingtomewhichtheindividual,

company,firm,corporation,orpublicagencymayhave,toincludeinformationordatareceivedfromothersources.

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