NHA Volunteer Screening Form

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


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