Criminal History Form

Step 3 of 5

Criminal History Policy
Due to the sensitive nature of the work performed in this program, individuals with certain types of criminal convictions may not be suitable for volunteering. Therefore, the program reserves the right to do a criminal history check at any time. Although some convictions; especially for such offenses as theft, abuse, neglect, or assault, may affect your suitability for volunteering, criminal convictions do not automatically disqualify you. The circumstances of each case will be evaluated against the requirements of the position to determine suitability for volunteering. Convictions as a juvenile will not be considered.

Criminal History Statement
In accordance with the program’s criminal history policy, the program reserves the right to perform a criminal history check at any time. In order that we may do so, please answer the question below.

Have you ever been convicted of a crime? YesNo

Date and State of Conviction:
Offense:
Sentence:

Note: In answering the above question, DO NOT report convictions that have been expunged, pardoned, or set aside; or arrests which did not result in a conviction; offenses as a juvenile; or offenses for which only a fine and no jail sentence was imposed.

Certification of Volunteer
I, (Your Name), hereby certify that I have read and understand the above policy. I further certify that all statements on this form and any addendum that I may have attached are true and correct to the best of my knowledge and I understand that any misstatements of material facts herein may result in my termination and/or forfeiture of all rights to service for Na Hoaloha. I further give my consent and authorize any representative of Na Hoaloha and/or other agencies to obtain information needed to verify any statements on this form. I further authorize the release of all criminal history records and information to Na Hoaloha. I further authorize copies of this document to be considered as an original.

Electronic Signature - Type Your Full Name (required)

Your Email (required)

By checking this box and typing my name above, I am electronically signing this release form. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
I consent to my submitted data being collected and stored.

(NOTE: These checkboxes MUST be checked in order to submit the form.)