14. Please list any volunteer/professional experience or skills relevant to the areas indicated in #13:

15. Have you ever been convicted of, or pled guilty to or "no contest" to a crime other than a minor traffic violation, or are you now under charges for any criminal offense?   Yes     No

If yes, please explain:

16. Do you have any health problems?   Yes     No

If yes, please explain:

17. Please list at least two personal references that have known you longer than one (1) year:

Applicant's Statement

Please read carefully before signing: The information contained in this application is correct to the best of my knowledge. I authorize any references listed in this application to give you information they may have regarding my character and fitness for volunteer work with students, and I release all such references from liability for any damage that may result from furnishing such evaluations to you.

Photograph and video release: I hereby grant Cresthaven Academy Charter School and Cresthaven Academy Foundation permission to the rights of my image, likeness and sound of my voice as recorded on audio or videotape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. I also understand that this material may be used in any school or foundation property, promotion or website.

Please Check:

Print Name:

Date:

Permission to Obtain a Background Check

(This form authorizes the foundation to obtain background information and must be completed by the applicant. The foundation must keep this completed form on file for at least two years after requesting a background check.)

I, the undersigned applicant (also known as "consumer"), authorize Cresthaven Academy Foundation through its independent contractor, SecureSearch, to procure background information (also known as a "consumer report and/or investigative consumer report") about me. This report may include my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; and the state sex offender records.

I understand that I am entitled to a complete copy of any background information report of which I am the subject upon my request to Cresthaven Academy Foundation if such is made within a reasonable time from the date it was produced. I also understand that I may receive a written summary of my rights under the Fair Credit Reporting Act.

Print Name:

Date:

Identifying Information for Background Information Agency
(also known as "Consumer Reporting Agency")

First Name

Middle Name

Last Name

Other Names Used (alias, maiden, nickname):

Current Address:

Apt #

City

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Zip Code

Former Address:

Apt #

City

State -- Select State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code

Social Security Number:

Telephone Number:

Driver's License Number:

State of Issuance:

Date of Birth:

Gender: