Program Name:

Location/City:

Child’s Name:

Volunteer First Name:

Middle Name:

Last Name:

Address:

Zip Code:

City:

State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregon SalemPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Cell Phone:

Email Address

T-Shirt Size: Adult SAdult MAdult LAdult XL

Date of Birth:

Drivers License Number:

Drivers License State:

Drivers License Expiration:

Have you ever been convicted of a crime? (if yes, please explain) yesno

Background Check Consent/Release
I authorize and give consent for the SSA Program to obtain my personal information to include but not limited to criminal background records, fingerprints, driving record and personal references.
I understand that my volunteer position is contingent upon information about my background and/or character discovered during the criminal history check.
I agree to hold harmless and indemnify from liability the SSA Program and its directors, officers, employees and volunteers from all liability arising out of the criminal history check.

I Agree

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