Volunteer Background Check

Personal Information

First Name:

Last Name:

Preferred Name:

Email Address:

Notice and Authorization for Background Check

This is to inform you Big Brothers Big Sisters of the Inland Northwest, herein noted as BBBS or BBSINW, may obtain information about you and/or your history related to potential criminal activity. The report from authorized sources may include, among other information, arrest, conviction, and final board disciplinary decisions. BBBS may additionally obtain information concerning your background, character, medical conditions, employment, education, and military experience. Information obtained by BBBS will be used only for the purposes of assessing your suitability to become a volunteer and matching you with a student.

As provided by State Law (RCW 43.43.830) a disclosure statement must be made by an applicant, and background inquiries may be made of certain civil adjudication's, conviction records or crimes against persons and disciplinary board final decisions prior to appointment to positions which have unsupervised access to youth.

Such inquiries may be made to state and/or federal law enforcement agencies. Information obtained from the disclosure statement, or from the background inquiries, will not necessarily preclude appointment, but will be considered in determining the applicant's character, suitability, and competence to person in the position applied for and may result in a denial of appointment. The use of the record of these inquiries will be restricted to the decision on your application and may be shared with the parent/guarding of the child you choose to match to.

If you wish to be considered for a volunteer or staff position, you must complete and sign this application and associated forms. Failure to do so will disqualify you for any volunteer or staff appointment.

Disclosure and Consent to Release of Information

1. Have you ever been convicted of or pleaded "guilty" or "no contest” to a felony or misdemeanor as an adult or juvenile? Include deferred or probated adjudications as well as convictions that have been set aside.

YesNo

If yes, give details including date, location and nature of the offense and disposition for each such incident.

I hereby authorize and instruct BBBS to procure a report on me, including a criminal background history, which I understand may include, among other information, arrest, conviction, and final board disciplinary decisions. I also authorize and instruct BBBS to verify my Social Security number and to investigate my background and character in any manner they see fit to evaluate my potential as a mentor, including obtaining information from employers, educational institutions, military agencies, and any other sources. If I become a volunteer for BBBS, I authorize BBBS to repeat these investigations at any time for as long as I remain a volunteer. I authorize BBBS to disclose relevant information obtained from its investigations to the parent/legal guardian of any student considered as a possible applicant to effectively enable the parent to exercise “parental choice” in accepting or denying me as a mentor for their child. I authorize and instruct any individual, corporation, and public or private entity having knowledge about me to furnish to BBBS any and all information they may have regarding me. I unconditionally release and hold harmless BBBS and its officers, directors, employees, and agents and any party furnishing information to them pursuant to this authorization from any liability, claims, charges, costs, or causes of action which I or my heirs, executors, or assigns may have as a result of the delivery, disclosure, non-disclosure, or omission of any information. I additionally agree to indemnify BBBS and its officers, directors, employees, and agents for any and all attorney fees, court costs, and other expenses resulting from investigating my background, gathering information concerning me, or verifying personal information about upon the written request of law enforcement agencies. BBBS uses technology tools to enhance personal relationships. Our online platform allows mentors, students, parents and BBBS to connect securely using a web application. Furthermore, I understand that BBBS holds the right to deny my participation in the program and, for confidentiality, is not required to disclose reasons for doing so. All parties agree that electronic/digital signatures are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. A photocopy of this authorization may be accepted in lieu of the original.

I Agree

2. Are you currently charged with (indictment or official criminal complaints by county or district court) a felony or misdemeanor?

YesNo

If yes, give details, including date, location, and type of charge.

3. Have you been or are you currently being investigated for allegedly abusing, neglecting, or exploiting a child, an elderly person, or a person with disabilities?

YesNo

If yes, give details, including the state and county in which each such investigation occurred..

I declare the information provided on this statement is true and correct. I understand that any misrepresentation or omission of the information requested may result in my being barred from providing direct services with BBBS. I also agree to inform BBBS if I am named in complaints, indictments, or convictions of offenses as described in items 1 & 2, or if I am investigated for allegations as described in item 3 of this form.

I authorize BBBS to verify any information provided by me through the investigative records maintained by BBBS and any other state protective services agency, as well as records of any law enforcement agency; local, state or federal. I consent to disclosure of any and all information, including confidential information, obtained from the above-referenced sources to BBBS in order to facilitate my volunteer service.

Yes

Printed Name of Person Completing Form:

Date Signed:

Individual's Identifying Information

First Name:

Middle Name:

Last Name:

List all other names you use or have used in the past, including married and maiden names, below, separated by a comma. If you do not provide every name used, we may receive inaccurate results:

Street Address:

City:

County:

State:

Zip Code:

Have you lived outside Washington in the last 5 years?

YesNo

Enter the previous physical address(es) of residence in last 5 years.

Date of Birth:

Birth City:

Birth State:

Gender:

Telephone Number:

Do you have a Social Security Number?

YesNo

Social Security Number:

Driver License or State ID Number:

Required Documents

Please submit your government issued identification:

If you're retired/veteran military, please submit a copy of your DD-214: