CONSENT TO CONDUCT BACKGROUND CHECK

CONSENT TO CONDUCT BACKGROUND CHECK
Date:*
MonthDayYear
Date
The Youth Connection, Inc. (TYC) is required to conduct a background check on all individuals 18 years of age and older including program participants, volunteers, chaperones, interns, mentors and/or independent contractors for all programs. Any previous acts committed and noted on your record does not automatically disqualify you from serving or participating. However, you will be evaluated based on all the information gathered. Acceptance as a participant, volunteer, chaperone, intern, mentor or independent contractor is at the sole discretion of The Youth Connection, Inc.
Name*
First NameLast Name
I __________________________(Print Your Name) hereby give consent for The Youth Connection, Inc. to conduct a background check for the purposes of participating, volunteering, chaperoning, interning, mentoring or working as an independent contractor for a TYC program(s This consent is in effect for up to one year from the above date.
Signature:*
Clear
Name*
(Please Print) *First Name*Middle Name*Last Name
Gender:*
Other Names (Maiden Name, Aliases, etc.):
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email:*
example@example.com
Race:*
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteHispanic or LatinoOther
Date of Birth*
MonthDayYear
Date
Phone Number
Area CodePhone Number
Cellular Phone*
Area CodePhone Number
Should be Empty: