BGCSCTN VOLUNTEER APPLICATION

VOLUNTEER APPLICATION

Volunteers are an extremely important part of Boys & Girls Clubs of South Central Tennessee’s daily operation. Mentoring a child can be a very rewarding experience; you can save a child’s life by being there for them. For these and many more reasons, Boys & Girls Clubs of South Central Tennessee has adopted a screening process for our volunteers as well as employees. Your cooperation with these policies is greatly appreciated.
Name

First NameLast Name
Home Phone
Home Address
Cell Phone
City
State
Zip
Gender
DOB
Race
DL#

Have you ever been affiliated with another Boys & Girls Club?
Location(s): Separated by Comma
Position held(s): Separated by Comma
All staff and volunteers are subject to an electronic background check, including motor vehicle reports, finger printing, criminal background investigation, and requesting a drug test.
I, First Name Last Name give Boys & Girls Clubs of South Central Tennessee permission to complete a background investigation on myself for the sole purpose of volunteering at “The Club” working with the members. I agree to and understand that Boys & Girls Clubs of South Central Tennessee is not and cannot be held liable in the event of accident or injury to myself.
In case of emergency please notify

First NameLast Name
City
State
State
State
Relationship
Work Phone
Cell Phone #

Date

MonthDayYear
Date
SSN
Email Address
example@example.com
High School
Last Year
College
Last Year
Degree
Currently in School?

YesNo
List volunteer positions held over last five years
I prefer to work with

List volunteer positions held over last five yearsGrades 6-12
Programs/activities you are interested in?
Hours per week you are available to volunteer?
Days of week most convenient for you?
Date available to begin?

MonthDayYear
Date
Total hours you wish to volunteer?
Will your volunteer time fulfill school, community service, personal, or organization required time? Please explain.
CHARACTER REFERENCES
Reference 1 Name

First NameLast Name
Reference 1 Email
example@example.com
Reference 1 Phone Number
Reference 2 Name

First NameLast Name
Reference 2 Email
example@example.com
Reference 2 Phone Number
We’ve been informed by our insurance company that, because you are not an employee, workmen’s compensation is not provided for you by our organization. Please see our Chief Executive Officer Ginny Wright if you have any questions. Also, be advised that a background check is run on any volunteer who works with Club kids.

Clear
Date

MonthDayYear
Date

AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION
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, credit history, civil record, workers’ compensation (post-offer only) and drug testing; 3. (For truck drivers only) In accordance with the Department of Transportation Motor Carrier Safety Regulations, Section 382.413, Information concerning alcohol and controlled substances for the past 3 years; 4. 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 employment application. This authorization shall remain in effect over the course of my employment. Reports may be ordered periodically during the course of my employment. NOTE: Except for those states where an annual release is required, i.e. California (CALIFORNIA-Continuing consent concept is inapplicable and a separate authorization must be requested each time a report is ordered. - CA Civ. Code 1786.22)

New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. You may also contact the Company to request the name, address, and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days.

New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer Identity theft protection, the storage and disposal of your credit information, and remedies available to you should you suspect or find that the Company has not maintained secured records is available to you upon request.

Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION
Background Investigation Pursuant to California Law. Please check this box and return this page if you would like to

receive a copy of an Investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California Law.
Special Applicant information

California applicants or employees only: By signing below you also acknowledge receipt of the Notice RegardingMinnesota and Oklahoma applicants or employees only: Please check this box and return this page if you would like to receive a copy of a consumer report if one is obtained by the Company
Full Name (Please print clearly)
Signature

Clear
Date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
State
Zip
International Address: If Applicable
DOB
SS#
Driver’s License Number
Email
example@example.com
Date of birth is being requested only for the purpose of identification in obtaining accurate retrieval of records, and will not be used for discriminatory purposes
Should be Empty:

VOLUNTEER APPLICATION

AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION

AUTHORIZATION AND RELEASE TO OBTAIN INFORMATION