Youth protection

Background check consent

Every adult who works with our students must complete a background check and safety screening. This form collects the information our trusted provider needs to run the check.

Your information

Full legal name *

Email *

Phone *

Date of birth *

Current full address *

ID type *

ID number *

References

Provide two people we can contact who know your character and work with youth or in your community.

Reference 1 name *

Reference 1 phone *

Reference 1 email

Reference 2 name *

Reference 2 phone *

Reference 2 email

Criminal record disclosure

Do you have any criminal record (arrests, charges, or convictions)? *

Answer honestly. A record does not automatically disqualify you — it is reviewed case by case and kept confidential. Providing false information does result in removal from the program.

Consent & signature

By signing below, you authorize Molding Young Minds to conduct a background check and safety screening, including criminal history and sex offender registry checks, and to contact your references. You understand that results are confidential, reviewed only by program leadership, and that you cannot work with students until the screening clears.

I consent to a background check and safety screening, and I agree that all information I provided is true and complete.

Type your full name to sign *