Information Release

Your Information

Name

First

Middle

Last

Your Address

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number

Date of Birth

Current Driver's License Number and State:

Give Permission

Background Check *

I understand it will be necessary for Field of Hope Mentoring Program to conduct a background check regarding my driving record, criminal history, personal references, and employment.

Additional Background Check *

I authorize Field of Hope to obtain any needed information regarding my driving record, legal/criminal history, character references, and employment from any state or federal agency, my employer, and personal references for the purposes of participating in a mentoring program. Further, I provide permission for Field of Hope to conduct the same investigation of my background in previous states in which I have resided.

Anonymity and Matching *

Further, I understand that information about myself will be anonymously (without my name) shared with a prospective mentee(s) and his/her parent(s)/guardian(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and any other information known about me may be shared with the mentee and parent/guardian to ensure and aid in facilitating a safe and successful match relationship.

Other Places of Residency

City and State

Lived There From

Lived There To

City and State

Lived There From

Lived There To

City and State

Lived There From

Lived There To

Your Signature

By signing above, I attest to the truthfulness of all information listed on this application and agree to all terms and conditions.

Electronic Signature Agreement: By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You consent to be legally bound by this Agreement's terms and conditions.

Name