Full Name of Applicant:

Other Names Used (including maiden name)

Social Security #

Date of Birth

Driver’s License/Identification Card # and State

Current Address: Street, City, State, Zip

Background Screening Agreement

I understand the volunteer position for which I am applying may require a background check. I provide the following information for that purpose.

Previous Addresses covering the past seven years:

Permission to Verify Documents

£ I give NHA permission to verify the credentials that I have presented, such as driver’s license, DMV record and/or medical licenses.

£ I do not give NHA permission to verify my credentials and understand that this decision may affect my options for volunteer placement.

Applicant Signature

Date

If volunteer is under 18 years of age, a parent or other designated adult must read and sign the following:

This release, its significance, and assumption of risk have been explained to and are understood by the minor.

Signature of Designated Adult                                                                               Date

Printed Name of Designated Adult