High Access and Individual Volunteer Application

High Access and Individual Volunteer Application
All High Access Volunteer applicants must pay the non-refundable $87 fee that covers background check expenses. Once you complete and submit this online form, you will receive a confirmation email that includes the link to our payment page. You will need to click on the link to pay this $87 fee, which completes your application.

Includes Application, Guidelines and Policies

Please complete this application and background check paperwork.

Upon notification of clearance of the mandatory background check, you will participate in a face-to-face interview to further determine and confirm your acceptance into our Mission Road Ministries’ Volunteer Program.

This form is HIPPA Compliant meaning all your personal information is encrypted and secure.

Thank you for your interest in serving as a volunteer at Mission Road Ministries.
Volunteer Application
First Name
Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at current address?
Email*
example@example.com
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Have you previously worked for or volunteered at Mission Road Ministries (Mission Road Developmental Center, Unicorn Centers)?*

YesNo
If yes, during what timeframe?
Volunteer Experience - list your volunteer experiences with non-profit organizations:
Please list your addresses in the past 7 years:

DPS Computerized Criminal History (CCH) Verification

(AGENCY COPY)
I, Applicant Employee Name* acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. Authority for this agency to access an individual’s criminal history data may be found in Texas Government Code 411, Subchapter F.

Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

In order to complete the fingerprint process, I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online Crime Records General Information | Department of Public Safety (texas.gov) Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company.

Once this process is completed the information on my fingerprint criminal history record may be discussed with me.
It is understood and you are in agreement with this typed signature serving as your official and legal signature.
Print Your Name*
Date*

MonthDayYear
Agency
Agency Representative Name

First NameLast Name
Date

MonthDayYear
Date
CCH Report Printed:

YesNo
Purpose of CCH:
Employee or Volunteer/Contractor?

EmployeeVolunteer/Contractor
Date Printed

MonthDayYear
Date
Destroyed Date

MonthDayYear
Date

Authorization

I hereby authorize procurement of consumer report(s) and investigative consumer
report(s) by Mission Road Ministries and its consumer reporting agency, Essential Screens. If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for Mission Road Ministries to procure such reports at any time during my employment, contract, or volunteer period. I authorize without reservation, any person, business or agency contacted by the consumer reporting agency to furnish the above-mentioned information.
In connection with my application for employment, I direct the following regarding my current employer: (please check one).*

Yes, my current employer may be contacted.No, my current employer cannot be contacted
I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the Summary of RightsInitials* (initials).

I authorize Mission Road Ministries to use email communication with me to provide me with notices and information regarding any report or use of such report. If I do not have an email address or do not wish to share it, then communication will be by U.S. Mail, which will result in slower communication.

If you have any questions concerning this background screening content, please contact:
Essential Screens
1821 North Webb Road, Suite 1
Grand Island, NE 68803
Printed Full Name (First, Middle, Last):*

First NameMiddle NameLast Name
It is understood and you are in agreement with this typed signature serving as your official and legal signature.
Signature*
Date*

MonthDayYear
Date
Email*
example@example.com
INFORMATION REGARDING YOUR RIGHTS

I understand that I have the right to make a request to the consumer reporting agency: Essential Screens, 1828 North Webb Road Suite 1, Grand Island, NE 68803, phone 888-494-9188, upon proper identification, to obtain copies of any reports furnished to Company by the Agency and to request the nature and substance of all information in its files on me at the time of my request, including the sources of information. The Agency will also disclose the recipients of any such reports on me which the Agency has previously furnished within the two year period for employment requests, and one year for other purposes preceding my request (California three years). I understand that I can dispute, at any time, any information that is inaccurate in any type of report with the Agency. I may view the Agency’s privacy policy at their website: www.essentialscreens.com

I understand that if the Company is located in California, Minnesota or Oklahoma, that I have the right to request a copy of any report the Company receives on me at the time the report is provided to Company. By checking the following box, I request a copy of all such reports be sent to me.
Initial here:Initials*

I understand that if I am applying for employment in New York, that I have the right to receive a copy of Article 23-A of the New York Correction Law Initials* (initial if this applies).

I understand that if the report is provided to an employer in the State of Washington, that I can contact the following office for more information regarding my rights under Washington state law in regard to these reports: State of Washington Attorney General, Consumer Protection Division, 800 5th Ave, Ste. 2000, Seattle, Washington 98104-3188, (206) 464-7744.

New Hampshire registered drivers: The consent for driving records is valid for only two (2) years and is revocable at any time.

Personal information in MVRs means information that identifies you, such as your photograph, social security number, driver’s license number, your name, your address, your telephone number and medical or disability information relating to any license restrictions. Highly restricted personal information includes your photograph or image, social security number, medical or disability information relating to any license restrictions. 18 U.S.C. §2725.

Acknowledged:
It is understood and you are in agreement with this typed signature serving as your official and legal signature.
Signature*
Date*

MonthDayYear
Date
Printed Full Name (First, Middle, Last, Suffix(Jr., Sr., II, III):*

First NameMiddle NameLast NameSuffix
Social Security #*
Date of Birth*

MonthDayYear
Date
Please select one:*

MaleFemale
Race*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Alias/Maiden/Previous Name(s)
The above is true and correct to the best of my knowledge:

It is understood and you are in agreement with this typed signature serving as your official and legal signature.
Print Your Name*
Date*

MonthDayYear
Date
Disclosure

In connection with my application for employment (including contract or volunteer services) with Mission Road Ministries, I understand consumer reports will be requested by you (“Company”). These reports may include, as allowed by law, the following types of information, as applicable: names and dates of previous employers, work experience, education, accidents, licensure, credit (as allowed by law – where required, you will be presented with additional disclosures), etc. I further understand that such reports may contain public record information such as, but not limited to: my driving record, workers’ compensation claims, judgments, bankruptcy proceedings, evictions, criminal records, creditworthiness, credit capacity, credit standing etc., from federal, state, and other agencies that maintain such records.

In addition, investigative consumer reports (gathered from personal interviews, as applicable, with former employers or landlords, past or current neighbors and associates of mine, etc.) to gather information regarding my work or tenant performance, character, general reputation and personal characteristics, and mode of living (lifestyle) may be obtained.

If I am hired, I understand that my employer can use this disclosure and authorization to continue to obtain such consumer reports throughout my employment, contract period or volunteer service.

Acknowledge:
It is understood and you are in agreement with this typed signature serving as your official and legal signature.
Signature*
Date*

MonthDayYear
Date
Printed Full Name*

Date

MonthDayYear
Date
Code of Conduct
My signature indicates that I have received a copy of the following Policy. It is understood and you are in agreement with this typed signature serving as your official and legal signature.
- Code of Conduct for Employees and Volunteers
Print Your Name*
Date*

MonthDayYear
Date
Should be Empty:

High Access and Individual Volunteer Application

Volunteer Application

DPS Computerized Criminal History (CCH) Verification

Authorization

Code of Conduct