I hereby authorize Legacy Grandparents/Help My Neighbour Society (HMNS) to contact any or all of the references listed herein for the purposes of processing my application to become a volunteer in the Society’s program. I understand that these references will be contacted in confidence.
I further authorize any individuals, firms, corporations, government or other regulatory departments, and Police Department or other organization to release information and copies of documents pertaining to myself to Legacy Grandparents/HMNS in order to consider my application to volunteer in the Society’s program, on the understanding that such information will be held in strict confidence.
I acknowledge and accept that this application does not guarantee acceptance into the program, and that Legacy Grandparents/HMNS is under no obligation to accept or assign me as a volunteer in their program, and is not obliged to provide a reason.
I give permission to Legacy Grandparents/HMNS to release pertinent information regarding my file to the parent of the youth and/or the young adult in the process of match selection.
Further, I agree to allow my file to be viewed by an Agency Reviewer for Legacy Grandparents/HMNS, at the time of the agency review, should it be requested.
I understand this application and subsequent information in my file is the property of Legacy Grandparents/HMNS.
The implications of the waiver have been explained to me. I understand and consent to them.
I further agree this waiver is made of my own free will and without distress.
Signature of Applicant: _________________