2024 Volunteer Interest Form

Legal Name*

First NameMiddle NameLast Name

Previous Legal Name

First NameMiddle NameLast Name

Social Security Number*

Date of Birth*

Date

Current Address*

Street Address

Street Address Line 2

CityState

Zip Code

How many years have you been at this address?

Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference 1:*

First NameLast Name

Reference 1 Phone:*

Please enter a valid phone number.

Reference 1 Email:

example@example.com

Reference 1's relationship to you*

Reference 2:*

First NameLast Name

Reference 2 Phone:*

Please enter a valid phone number.

Reference 2 Email:

example@example.com

Reference 2's relationship to you*

I , __________________ hereby give my full consent and permission to Boys & Girls Clubs of Elkhart County, to obtain information relating to my criminal history and any other applicable records including, but not limited to my Motor Vehicle Records through VeriScreen, the Indiana Sheriff’s Department, IOI and/or other agencies not previously mentioned and their agents.

Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., the Americans with Disabilities Act and all applicable federal, state, and local laws, I hereby authorize and permit VeriScreen, Inc. aka VeriRent to obtain a consumer report and/or an investigative consumer report which may include the following:

1. My employment records;
2. Records concerning any driving, criminal history, civil record, workers’ compensation (post-offer only) and drug testing;
3. Verification of my academic and/or professional credentials; and information and/or copies of documents from any military service records.

I understand that an "investigative consumer report" may include information as to my character, general reputation, personal characteristics, and mode of living, which may be obtained by interviews with individuals with whom I am acquainted or who may have knowledge concerning any such items of information. I am entitled to know if employment or promotion is denied because of information obtained by my prospective employer from a Consumer Reporting Agency.

I agree that a copy of this authorization has the same effect as an original and if my application is accepted I understand that VeriScreen will be allowed to perform a background check on a yearly/quarterly or during the process of determining a promotion, re-certification, continued qualification or as the result of reasonable suspicion.

I understand and acknowledge that under provision of the Fair Credit Reporting Act I may request a copy of any consumer report from the consumer reporting agency that compiled the report after I have provided proper identification.

I authorize VeriScreen, Inc. aka VeriRent to obtain and prepare an investigative consumer report as set forth above, as part of its investigation of my volunteer application. This authorization shall remain in effect over the course of my volunteer service. Reports may be ordered periodically during the course of my volunteer service.

Background Check Consent*

I ACKNOWLEDGE THAT I HAVE READ AND FULLY UNDERTAND THE CONSENT FOR THE ABOVE RECORDS CHECK AND THAT I ACCEPT AND SIGN THIS FORM VOLUNTARILY AND DIGITALY

Digital Signature*

Today's Date*

Date

Thank your for submitting your information to volunteer with our clubs. Please click submit to finalize your application. We will reach out to you soon to talk with you on volunteering.

Thank You,

Boys & Girls Club of Elkhart County Team

Volunteer Interest Form

Your Information

How would you like to volunteer?

Application for criminal background check and driving record screening.

Your Information

References

Authorization and Release to Obtain Information