JH Christmas Outreach Clearance Form

JUVENILE INSTITUTION VOLUNTEER AUTHORIZATION

REQUIREMENTS: You must be 21 years old or older, No felony convictions in the past three years or misdemeanor convictions in the past one year, off probation or parole, and you must have a valid photo identification.
Legal Name

First NameMiddle NameLast Name
Address on ID*

Street Address

Apartment, Condo, or Space Number

CityState

Zip Code
E-mail*
example@example.com
Cell Phone Number*

Area CodePhone Number
Birthday*

MonthDayYear
Date
Driver's License Number*
Please include the state you got it in
Expiration Date*

MonthDayYear
Date
Type of Activity: Juvenile Hall Christmas Outreach

Monday, December 11th

Arrival Time: 5:30 pm

Program Time: 6:30-8:15 pm
Requested By: Chaplain Rick Johnson
Probation Record: No ____ Yes ____     

If Yes: Active ____ Inactive ____   

A/J Number: __________________     

Record Checked By: _______________    

Authorized By: _____________________________     Date: _____________    

Denied By: _________________________________ Date: ______________
Should be Empty:

JUVENILE INSTITUTION VOLUNTEER AUTHORIZATION