CONSENT FORM
I, ____________________________________________,* agree to the following Criminal History Checks to be performed in order to serve as an AmeriCorps Member or work as an employee with AmeriCorps Project CHANGE :
- NSOPW Public Sex Offender Check
- Statewide Repository Checks (for State of Service and State of Residence)
- FBI fingerprint-based Check
I am aware that that my identity must be verified with a government issued photo ID. I understand that the results of these checks will be kept confidential, but could affect my eligibility to serve in AmeriCorps or work as staff with AmeriCorps Project CHANGE. I am aware that I have the right to review the findings. I also understand that selection into the program is contingent upon successful clearance of these checks and a search of the National Sex Offender Public Website. If I have past convictions for murder or am required to register as a Sex Offender, these will make me ineligible for these positions. I am also aware that any attempt to cover up or deceive with regard to my past criminal history may also disqualify me.
*Please include any aliases or names previously used such as maiden names:
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| Applicant Signature: | Date: | |||
| Parent Signature if Applicant is under 18: | Date: |