BASIC INFORMATION
Full Legal Name
First Name *
Last Name *
"Goes by" Name
Street Address *
City *
State *
Zip Code *
Email *
Phone *
Date of Birth *
Gender *
 Male Female
Do you currently volunteer for Healing Haiti?
 Yes No
If yes, where?

PERSONAL HISTORY
Have you been convicted of a felony? *
 Yes No
If yes, please explain:
Emergency Contact Information
First Name *
Last Name *
Relation *
Phone *
Additional Information
Religious Background *
Current Church *
Top 5 Spiritual Gifts
1 *
2 *
3 *
4 *
5 *

VOLUNTEER INFORMATION
Why are you interested in volunteering for Healing Haiti? *
I would like to be considered for the following volunteer opportunities *
Have you volunteered for other organizations? *
 Yes No
(If yes, please list the names of the Organizations)
What job-related qualifications, skills, and/or experience could you apply to this position? (Include educations/degress, places of employment) *
What type of commitment can you offer *
 One-Time Once in a while Ongoing Leadership/Heavy
Please explain *
Please attach your Resume, if available

BACKGROUND CHECK
Healing Haiti is committed to providing a safe and secure environment for its volunteers, staff, and the people we serve. It’s critical that Healing Haiti volunteers have no history of criminal behavior relevant to their serving position. In order to ensure this safety, Healing Haiti requires background checks and/or personal interviews to screen for certain volunteer serving roles. These roles include, but are not limited to, anyone working with minors, anyone working with money, and/or serving in an ongoing volunteer position, Coach, Team Leader or Advocate level role.

Please complete the BACKGROUND CHECK release.
First Name *
Middle Name *
Last Name *
Maiden or previous name:
First Name
Middle Name
Last Name
Date of Birth *
Social Security Number *
Gender *
 Male Female
Street Address *
City *
State *
Zip Code *
Email *
Phone *
Have you ever been accused of sexual improprieties with children or youth? *
 Yes No
have you ever been found guilty of sexual improprieties with children or youth? *
 Yes No
Under Minnesota law you have the right to request a free copy of any report procured on you
 Email a copy to address above I do not wish to receive a copy Mail me a copy to address above
By submitting this online form, I give Healing Haiti the right to investigate all references and to secure additional information about me. I hereby release Healing Haiti, and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

TERMS & CONFIDENTIALITY STATEMENT
Terms: I agree that all the questions contained in this application were answered honestly and truthfully to the best of my knowledge. All points acknowledged with my signature were done so with the full intent of abiding by these guidelines.

I hereby give my permission for Healing Haiti to obtain information pertaining to any convictions I may have under state and federal law. The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudication. I understand that this information will be used, in part, to determine my eligibility to be a volunteer with this organization. I also understand that as long as I remain a volunteer here, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review my criminal history report and a procedure is available for clarification, if I dispute the record as received.

I, the undersigned, do for myself, my heirs, executors and administrator, hereby remise, release and forever discharge and agree to indemnify Healing Haiti and each of the officers, directors, employees and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever, and any and all related attorneys’ fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer.

I understand and agree that as a part of my application, I am agreeing to be bound by the Bylaws, Doctrines and Policies of Healing Haiti, and to refrain from unbiblical conduct in the performance of any services on behalf of this organization. If, at any time, I am out of accord with any of these, I agree to withdraw or be withdrawn from my serving position.

Confidentiality Statement: Information obtained as a result of the criminal background investigation will be maintained on a confidential basis in Human Resources and may be shared with the hiring unit or applicable upon request and/or pursuant to applicable provisions as stipulated by this policy.

Date (Select Today's Date) *