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  • Personal Information
























  • (if applicable)
  • Availability








  • References

    List three (3) references NOT related to you whom you have known for more than one year.


















  • Volunteer / Employment Experience

    List your most recent volunteer or employment experience
  • Failure to disclose, by false statement, misrepresentation, impersonations or other fraudulent means, any material fact used in making a determination as to a person’s qualifications to work with children, developmentally disabled children and adults, and the frail elderly is a misdemeanor of the first degree.   

    I understand that, to protect individuals served by the department, a routine check through law enforcement, license bureaus, agency files and references may be made. I understand that a criminal offense will not automatically exclude me from all volunteer positions; however, certain convictions will exclude me from volunteering in some positions. I understand that applications submitted for state volunteer services are public records.   

    I understand and agree that all information as it relates to child abuse records and clientele are confidential under s. 415.513, Florida Statues. I further agree to treat all information on clients that should come to my attention and knowledge as privileged and confidential, and that I will not disclose such information to anyone other than authorized persons.


  • Date Format: MM slash DD slash YYYY

  • Mentor Release Form

    The following information is needed to conduct law enforcement checks and EEO surveys.







  • I have agreed to serve as a mentor for Embrace Families’ Legacy Mentor Program. I understand that as a volunteer mentor with this program, I may learn certain facts about the young adults and families served by Embrace Families that is confidential. Such confidential information may include, but is not limited to, details of the child or family’s personal, medical, financial, and employment history, particular reasons the youth came into care, treatment plans and Family Court findings. I agree, as a condition of my service as a volunteer mentor, not to disclose any such confidential information to any person who is not an employee of Embrace Families affiliated with Embrace Families’ Legacy Mentor Program.

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  • The information I have provided on this questionnaire is true to the best of my knowledge. I grant permission to Embrace Families to verify the information and to contact the references provided.

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  • DISCLOSURE AND CONSENT CONCERNING CONSUMER AND INVESTIGATIVE CONSUMER REPORTS

    This form, which you should read carefully, has been provided to you because Embrace Families may request Consumer Reports and/or Investigative Consumer Reports from a consumer reporting agency. The Company will use any such report(s) solely for employment-related purposes.

    Consumer Reports or Investigative Consumer Reports will be obtained from HireRight, Inc., (“HireRight”) located at 2100 Main Street, Suite 400, Irvine, CA 92614. They can be contacted at 800-400-2761. Any such reports may contain information bearing on your character, general reputation, personal characteristics, mode of living and credit standing. The types of information that may be obtained include, but are not limited to: social security number, criminal records checks, public court records checks, including civil, driving records, verification of employment positions held, personal and professional references, licensing, certification, etc. The information contained in these reports may be obtained by HireRight from private or public record sources including sources identified by you in your job application or through interviews or correspondence with your past or present coworkers, neighbors, friends, associates, current or former employers, or other acquaintances.

    You are being given a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act” prepared pursuant to 15 U.S.C. section 1681(g)(c). You have the right to request additional disclosures of the nature and scope of the investigation and a statement of your rights by contacting HireRight.

    CONSENT

    I have carefully read and understand this Disclosure and Consent form and, by my signature below, consent to the release of consumer and/or investigative consumer reports, as defined above, to the Company in conjunction with my application for employment. I further understand that any and all information contained in my job application or otherwise disclosed to the Company by me before, during or after my employment, if any, may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports requested by the Company. I understand that if the Company hires me, it may request a consumer report and/or an investigative consumer report about me, as defined above, for employment-related purposes during the course of my employment. I understand that my consent will apply throughout my employment, to the extent permitted by law, unless I revoke or cancel my consent by sending a signed letter or statement to the Company at any time. This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by the Company.




























  • Date Format: MM slash DD slash YYYY

    (for ID purposes only)