BACKGROUND CHECK Each participant in a Hope on the Ground short-term team must complete this form in advance. By submitting this form, you consent to Hope on the Ground running a background check for you. Team Name * Select... KeHE Employees - September 2025 Barnhart - October 2025 CenterPointe Men - October 2025 KeHE Trip Leaders - October 2025 Movement Foundation - October 2025 Vision Team - October 2025 Blue Trust/Movement - November 2025 Advent Chicas - January 2026 St. Mary's Goochland - January 2026 PERSONAL INFORMATION Name (as on passport) * First Name Last Name List any other names previously used. Including maiden name, if married. Date of Birth * MM DD YYYY Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country CRIMINAL HISTORY Have you ever been committed of a sex-related crime? * Yes No Have you ever been convicted of a crime involving violence or threat of violence? * Yes No Have you ever been convicted any other crime (including traffic crimes) except a minor traffic violation? * Yes No Have you ever been arrested within the last three years for a crime for which there has not yet been an acquittal or dismissal? * Yes No Please explain any "yes" responses. DIGITAL SIGNATURE * Thank you!
