Volunteer

Name*

First Last

Email*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Birth Date*

MM

DD

YYYY

Programs you're interested in volunteering with*

Youth programs
Community outreach/events
Community bike shop
Office/administrative

check all that apply

Have you ever been convicted of, pled guilty or nolo contendere (neither admitting nor denying the charge) to, or received a suspended imposition of sentence, been placed on probation, or otherwise been found guilty of any criminal or municipal ordinance violation?*

Yes
No

Have there ever been allegations, complaints, or reports regarding your involvement in child abuse or neglect (regardless of whether the incident was confirmed or denied)?*

Yes
No

I understand that any omissions or misstatements made by me on this background check form may be cause for my application to be declined or volunteer placement to be terminated. I understand that a Michigan State Police criminal background check will be conducted and all information including conviction or child abuse records will be verified, and hereby consent to such verification. I declare that all the statements I have made on this form are true, correct, and complete to the best of my knowledge. I understand El Grupo Norte Youth Cycling, in their sole and complete discretion, may accept or decline this application without providing me any reasons for the decision.*

I agree

Pursuant to Board Policy 1001, I understand and release El Grupo Norte Youth Cycling of any obligation should I suffer any risk or loss as a result of my volunteer services.*

I agree

Comments?

Volunteer

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