BACKGROUND CHECK Each participant in a Hope on the Ground short-term team must complete this form prior to their time in country. By submitting this form, you consent to be the subject of a background check that Hope on the Ground will run on your behalf. Team Name * Select... CenterPointe Men - November 2024 Squid Lips - December 2025 KeHE Cohort K - January 2025 Christ Church Charlottesville - January 2025 Vision Team - Jan/Feb 2025 St. Mary's Goochland - February 2025 Sewanee - March 2025 Chapel of the Cross ECM - March 2025 CenterPointe - March 2025 Winston-Salem Fellows - March 2025 KeHE Employees - April 2025 KeHE Team and Board - April 2025 Chapel of the Cross Youth - June 2025 Chapel of the Cross Adults - June 2025 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!
