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.
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