Adult Volunteer Background Check Consent Form

Adult Volunteer Background Check Consent Form

The data entered on this form is encrypted for your safety. No physical copies of this information will be stored. Please complete the form carefully for submission.

Full Legal Name

First NameMiddle NameLast Name

Alias or Maiden Name (if any)

First NameLast Name

Additional Alias (if any)

First NameLast Name

Birth Date

MonthDayYear

Gender

Social Security Number

Required

Your Student's Name(s)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter the following information to allow us to contact you if we have any questions about your application. Thank you.

E-mail

example@example.com

Phone Number

By completing this form, you hereby authorize Kansas City Homeschool Connection to procure a criminal background report which may include information regarding your character, general reputation, or personal characteristics. This report may be compiled with information from court record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing registration entities, business or personal references, and any other sources required to verify that you are eligible to work with minors. You may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such investigation includes information bearing on your character, general reputation, or personal characteristics.

Please acknowledge that you understand and consent to this background check by checking the box below.

YesNo