YWCA GAMECHANGERS

Name:

Address:

Do you have reliable transportation? *

Do we have permission to conduct a background check?*

Has there ever been a found allegation of child abuse or neglect against you?*

Have you ever received treatment for alcohol or substance abuse?*

Have you ever been hospitalized for mental health reasons?

Are you willing to commit to Game Changers for 1.5-2 hours per week for up to a year?*

Please read the following statements and check the box if you agree:

I agree to follow all GameChangers rules, policies, and procedures, and I understand that any
violation will result in suspension and/or termination of my participation in this program.

I understand that GameChangers/YWCA Knoxville & the Tennessee Valley/Partner Organizations are not obligated to provide a reason for their decision in accepting or rejecting me as a mentor.

I agree to allow GameChangers/YWCA Knoxville & the Tennessee Valley to contact my
personal/professional references listed on the following page.

In the space below please provide three non-family references. At least one must be a prior supervisor or
someone who knows you professionally.

Reference 1:

Address:

Reference:2*

Address:*

Reference:3*

Address:*

In the space below please provide contact information for your spouse, significant other, or non-family member friend.

Address*

Information Release

I understand that it is necessary for GameChangers/YWCA Knoxville & the Tennessee Valley/Partner Organizations, to conduct a background check regarding my criminal history, employment, and personal references.*

I authorize GameChangers/YWCA Knoxville & the Tennessee Valley/Partner Organizations, to
obtain any needed information regarding my criminal history, employment, and personal
references from any state or federal agency, my employer, and provided personal references for
the purposes of participating in GameChangers. I authorize GameChangers/YWCA Knoxville & the
Tennessee Valley/Partner Organizations to conduct the same investigation of my background in
previous states in which I have resided. *

Please list any other cities, states, and dates of residency during the past 5 years:

Address*

Address*

This project was supported by Grant No. 2013-CY-AX-K003 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication/program/exhibit are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women.

Once clicking "submit," here is what you can expect next:
1. Your application will be submitted online
2. We will contact your references
3. Your profile will be checked on National Sex Offender Registry and TN Department of Health: Abuse Registry
4. We will contact you and schedule an interview
5. We will have you fill out and sign VECHS Waiver Agreement and Statement
6. You will be asked to get a fingerprint background check; further instructions will be provided later.