INFORMED CONSENT

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The following named individual has made application to volunteer with this entity.
Date:
Date:
Name
Name
Please include your middle name as well:
Home Address:
Home Address:
Previous Address (if you have resided at your current address for fewer than 5 years)
Previous Address (if you have resided at your current address for fewer than 5 years)
Date of Birth:
Date of Birth:
Gender:
I authorize Protect My Ministry to disclose all criminal history record information to The Evangelical Free Church of Redwood Falls for the purpose of volunteering with this entity. The expiration of this authorization shall be one year from the date of my signature.
Date:
Date:
Date:
Date:
You have the right, upon written request made within a reasonable time after the receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report prepared by contacting the Evangelical Free Church of Redwood Falls and Protect My Ministry 14499 N. Dale Mabry Hwy., Suite 201 South, Tampa, FL 33618; Phone: 1-800-319-5581. For information about Protect My Ministry’s privacy practices, see www.protectmyministry.com.