This form is to gather general information for volunteer’s who wish to have any hands on contact with survivors |

Name *

First

Middle

Last

Have you ever gone by any other names (maiden names, former married names, etc.)? *

If Yes, please put name here.

Date of Birth *

Address *

City *

State *

Zip *

Email *

Have you lived at this address for more than 3 years? *

If NO, please put previous name of City and State here

Do you hold a current US driver's license? *

Marital Status *

How many people live in your current home? *

People in your home (drop down) *

Any and all persons listed above the age of 18 who reside in a safe house needs to fill out a form to grant permission to run a background check.

Why do you want to help and what is your knowledge about the Amish and Mennonite people? *

Do you live in or near an Amish or Mennonite community? *

Agreement *

I agree that the information shared above is true and correct and grants permission to Amish Rescue Mission to run a background check on me. The information contained on this form is true and correct to the best of my knowledge. I agree to all terms therein. By checking yes above and signing below, I consent to a background check.

Signature *

PRINT FULL NAME AND BIRTHDAY TO AGREE

Reference #1 *

Full name and your friendship

Email or Phone # *

Full name and your friendship

Reference #2 *

Full name and your friendship

Email or Phone # *

Full name and your friendship

Reference #3 *

Full name and your friendship

Email or Phone # *

Full name and your friendship

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