First Name *

Last Name *

Address *

City *

State *

Zip Code *

Date of Birth *

Gender *

Race (Required for background check) *

Do you require special accommodations for physical limitations? *

If "Yes," Please explain

Please list work/occupation

Do you have a valid driver's license? *

Please provide your drivers license/state ID number and issuing state. Ex *

Have you ever been convicted of a crime other than a traffic violation? *

If yes, please describe (date, crime, court disposition, and circumstances).

Are you currently on probation or parole *

I certify that the above information is true. I understand that any false or misleading information is grounds for denying or terminating my volunteer placement. I acknowledge understanding that the Police Department will conduct a review to determine suitability for program participation and any such responsive information will not necessarily disqualify me. I further understand that the content of this application and a determination of the Police Department approval to serve as a Volunteer ANGEL (to include disqualifying factors) will be shared with our partners: Hope Not Handcuffs Coordinator, Tri-County Community Partnership Inc. I hereby release from liability and agree to hold harmless; under any and all possible cause of legal action, including negligence, Hope Not Handcuffs, Tri-County Community Partnership Inc., the police department, and any of their officers, agents or employees for any neglect or wrongful statements, acts, omissions made or recorded in the course of my background check. Having read the ANGEL Description document, completed the above application form and read the Background Information Check process, I hereby request to be considered to serve as a Hope Not Handcuffs Volunteer ANGEL. *