Volunteer Screening

The NSA realizes it is important to institute certain safeguards because many activities occur away from the NSA National Office (local youth, teen and adult chapters, Youth Days, regional meetings, etc) and involve children, teens, and vulnerable adults. Therefore, it has implemented the screening process to help ensure the protection of the children, teenagers and/or vulnerable adults participating in events sponsored by the NSA.

This screening form must be completed by all persons requesting to volunteer in a leadership capacity and who will be engaging in any National Stuttering Association (“NSA”) activities with or around children, teenagers, and/or vulnerable adults. This is not an employment application. The information provided in this screening form is used to help the NSA provide a safe and secure environment.

NOTE: Anyone wishing to serve as a Chapter Leader MUST reach out to their Regional Chapter Coordinator (RCC) before submitting this form. Your RCC or Family Programs RCC can be found on your state page in our NSA chapter directory.

Chapter Leader Volunteer Screening Consent Form

Volunteers are required to fill out the application and background criminal (not credit) check below before being approved as Chapter Leader, Regional Chapter Coordinator, Family Chapter Leader or any other NSA event.

Step 1 of 2

Full Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone
Date of Birth*
Last 4 digits of Social Security Number*
Current Employer*
Name and address of current employer
What Volunteer Position are you applying for?*
Do you currently have pending charges for any criminal offense involving minors or violence?*
Have you ever been refused participation in any youth programs?*
If yes, please contact Executive Director to discuss.
Have you ever been convicted of, pled guilty or no contest to, placed on probation for, given community supervision for or given deferred adjudication for, any crime involving minors or violence?*
Have you ever been refused an opportunity to volunteer for an organization?*
If yes, please contact Executive Director at tflores@westutter.org to discuss.
Briefly explain why you would like to volunteer for NSA*

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Authorization for Background Check and Release of Claims*
I understand the National Stuttering Association (“NSA”) requires a general background check, including criminal history, for its leadership volunteers. I authorize, without reservation, the NSA to obtain, and any party or agency contacted by a consumer reporting agency (“CRA”) to furnish, any and all information and records relating to my background which may reflect upon my potential to volunteer for the NSA. This information may include, but is not limited to, criminal history records, information on any committed or alleged criminal acts or offenses, and/or arrests, including any act of child abuse, and sex offender registry information. I knowingly release the NSA from any and all liability arising from or relating to obtaining or using this information. The CRA is authorized to disclose all information obtained to the NSA for any lawful purpose. This authorization shall remain on file and serve as ongoing authorization for the procurement of consumer reports. I also understand and authorize any references, whether or not identified by me, to give information (including opinions) regarding my character and fitness. I knowingly release any reference contact, whether or not identified by me, from any and all liability on account of compliance with this authorization. I further knowingly release the NSA from any and all liability arising from or relating to obtaining or using this information. I am aware that background checks may be updated periodically at the sole discretion of the NSA. By signing below, I certify that I have carefully read and fully understand this legally binding release, that prior to signing, I was given an opportunity to consult with an attorney (if desired), and to ask questions, and to have those questions answered to my satisfaction, and that I executed this release voluntarily.
- Yes, I consent
- No, I do not consent
Acknowledgement of Volunteer Status and Release of Claims*
I acknowledge that by submitting this form, I am requesting to be considered as a volunteer only. If I am accepted as a volunteer, I understand that I am not an employee of the NSA and do not expect to be treated as an employee for any purpose, including but not limited to, compensation and/or fringe benefits. To that end, I release NSA from any liability from any claims, including claims alleging an employment relationship. I also agree to save, hold harmless and indemnify NSA from any liability resulting from such claims.
Please type Full Name*
NSA requires a general background check, including criminal history, for all individuals who want to volunteer. This background check may be repeated at periodic intervals at the discretion of the NSA. By signing your name you hereby consent to the National Stuttering Association running a background check.

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Chapter Leader Volunteer Screening Consent Form

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