Prospective Board Member/Committee Member
Name:
Address:
Date:
DOB:
Phone:
Work Phone:
E-mail:
Is it OK to contact you at work?
Yes
No
Board Member Applicant
Committee Member Applicant
Educational Background: (Please mark all that apply)
High School
Associate Degree
4 year Undergraduate Degree
Masters Degree: ________
Ph.D: ________________
Other: ________________
Employment: (Please attach a current resume)
Employer:
Title/Position:
Length of Employment:
Is the above address where you would like you Best Friend's information sent?
YES
If not, where?
Please check the education/skills you can contribute:
Accounting
Board Development
Business Connections
Cross-Cultural Skills
Community
Connections
Education
Financial Mgt
Fund Development
Graphic Design
Human Services
Insurance
Legal
Marketing/ PR
Program Dev.
Psychology
Public Speaking
Strategic Planning
Technology
Volunteer Mgt
NO
Are you presently volunteering on any other boards? For whom?
Community Involvement: (List organizations/type of volunteer work you do.)
What has prompted your interest in Best Friends of Neenah-Menasha? What is your understanding
of our organization?
Personal Interests?
Title:
Reviewed Date:
Reviewed By:
Caregiver Background Check
February 8, 2006
Personnel Committee
Policy/Purpose
In agreement with the Wisconsin Caregiver Background Check Law, all covered Best Friends of NeenahMenasha Inc. ("Best Friends") applicants (after an employment offer has been made), employees, and
volunteers (Best Friends board members, mentors, and committee chairs) will be subject to background
checks. Best Friends of Neenah-Menasha will verify the information with CCAP (Circuit Court Automated
Program), CIB (Criminal Investigation Bureau), local & state police check, the Wisconsin Sex Offender
Registry, and/or other agencies. Falsification of any information provided to Best Friends of NeenahMenasha may result in denial of employment and volunteer services or may be grounds for discipline, up to
and including termination of employment or volunteer services. Any applicant, employee, or volunteer that
does not meet the criteria set forth in the Caregiver Background Check Law, or who has been convicted of a
crime substantially related to client care, may be barred from employment or volunteer services with Best
Friends of Neenah-Menasha or may be placed under certain restrictions.
All employees of Best Friends of Neenah-Menasha shall notify the Executive Director in writing when any
events listed below have occurred since the completion of the employee's "employment application." All
volunteer of Best Friends of Neenah-Menasha shall notify their Program Services Coordinator in writing
when any events listed below have occurred since the completion of their "interview." Notification must be
made as soon as possible and should be made no later than the next working day following the event. Failure
to provide Best Friends of Neenah-Menasha with required notice may lead to discipline up to and including
termination of employment or volunteer services.
Events that must be reported:
1. Pending criminal charges (arrests) or conviction of any crimes as listed in the offenses list under the
Caregiver Background Check Law applicable to all employees and volunteers 18 years or older.
2. Investigation or finding by any governmental agency regarding any act, offense, or omission, including
an investigation related to the abuse or neglect, or threat of abuse or neglect, to a child, or other client,
or an investigation related to misappropriation of a clients property.
3. Denial, restriction or other limitation by the Department of Regulation and Licensing of any license
required to perform duties at Best Friends of Neenah-Menasha.
__________________________________________
Signature
______________________________
Date
_________________________________________
Please Print Name
Guardian Signature if under 18 yrs.
Dear Chief of Police/Sheriff, __________________________________________. Date:
The following is our Police Release of Information Form. The person listed below is applying to be a
volunteer mentor in Best Friends of Neenah-Menasha, Inc., a program that matches adults with children.
For the safety of the children, will you please do a police records check on this volunteer? A stamped,
self-addressed envelope is enclosed. If it is more convenient, you can FAX this form to us at 920-7299045.
Thank you.
Dawn Gohlke, Executive Director
POLICE PERMISSION FORM
I hereby give my permission to allow a background investigation concerning police contacts in the cities
and
states listed below and to release this information to Best Friends of Neenah-Menasha, Inc.
Signed:
Date:
(Please Print)
Complete Name:
(First Name)
(Middle Name)
Address:
(Last Name)
City/Zip:
How Long At This Address?
Maiden Name:
Date Of Birth:
Place:
Sex:
Race:
Driver’s License Number:
Please State All Previous Residences Within The Last Five Years
(Include Name of City or County Law Enforcement Agency)
Address
City
State
Zip
Dates
181 E. North Water St.  Suite 225  Neenah, WI 54956
Phone 920-729-5600 FAX 920-729-9045
e-mail: info@bestfriendsnm.org
Website: www.bestfriendsnm.org
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