Volunteer Application Form - Santiam Teen Center

Background Check

Full Name*

First NameMiddle NameLast Name

Former Last Name (if name has changed)

SSN*

Date of Birth*

Date

Email*

example@example.com

Phone Number*

Area CodePhone Number

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you ever been convicted of or pled guilty of a felony crime?*

YesNo

If yes, in which state? Please explain

Have you ever been accused of child abuse?*

YesNo

If yes, please explain

Name*

First NameLast Name

Church Affiliation*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please describe why you are interested in volunteering at the Teen Center?*

Please list and explain any volunteer service or work with youth that you have been involved with:*

Organization and Description. How long?

What are your strengths, talents, and interests that you might be willing to share with students?*

What is your availability for helping with the Teen Center?*

Days of the week & times

Reference #1*

Name, Address, Phone Number, Relationship

Reference #2*

Name, Address, Phone Number, Relationship

Reference #3*

Name, Address, Phone Number, Relationship

I acknowledge that the information I have provided is true and correct.*

Yes

Signature*

By entering your name, you consent to signing this document electronically.

Authorization and Release for Background Check

I hereby authorize the Santiam Teen Center and its representatives to conduct a thorough background investigation to determine my suitability for volunteering with youth. I understand this may include, but is not limited to:

Criminal history
Sex offender registry checks
Verification of identity and addresses

I voluntarily provide my consent for these checks and release from liability the Santiam Teen Center, its agents, and any individuals or organizations providing information in good faith.

I affirm that all information provided on this application is true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission may disqualify me from volunteering or result in dismissal if already accepted.

I understand that the results of this background check are confidential and will be used solely for the purpose of determining my eligibility to volunteer in a capacity involving minors.

I waive any right to inspect the results and acknowledge that final decisions rest solely with the Santiam Teen Center.

Describe any painful life experiences you had as a child/minor which may affect you while working with youth? Please explain.*

I hereby state my understanding of the Background Check policy of Santiam Teen Center and give my consent for a background check through Protect My Ministry.*

Yes

Signature*

By entering your name, you consent to signing this document electronically.

I am over the age of 18 and acknowledge and show compliance with the above statements*

Yes

Signature*

By entering your name, you consent to signing this document electronically.