Volunteer Background Check Disclosure

BACKGROUND CHECK DISCLOSURE

The Scottsbluff Family YMCA intends to obtain a consumer report (background check) on you for volunteer purposes. This report may be used to evaluate your suitability for a volunteer position within our organization. The following screens provide a Summary of Your Rights Under the Fair Credit Reporting Act, followed by a separate form to collect your identifying information and signature authorizing this check.

AUTHORIZATION & DATA COLLECTION

Please complete all required fields to authorize a background check.
First Name
Full Middle Name
Last Name
Date of Birth

MonthDayYear
Date
Social Security Number
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip Code
Authorization

By signing below, I expressly authorize YMCA of Scottsbluff to obtain a consumer report (background check) through ADP Screening for volunteer purposes. I authorize ADP Screening to release to YMCA of Scottsbluff any information pertaining to my criminal history. I understand that the consumer report may include criminal history, driving records, and other public records, as permitted by applicable law.
Signature
Date

MonthDayYear
Date
Should be Empty:

BACKGROUND CHECK DISCLOSURE