WAKE FOREST BAPTIST MEDICAL CENTER VOLUNTEER SERVICES
AUTHORIZATION FOR RELEASE OF INFORMATION & RECORDS
I, ______________________________________________, understand that in consideration of my application, an investigation will
be conducted. I authorize Wake Forest Baptist Medical Center Volunteer Services, through its agent, Investigative Associates &
Consultants, Inc., to conduct such an investigation which may include, but not be limited to, the gathering of information regarding
verification of prior employment, references, consumer credit history, driving history, and any criminal history which may be in files
of any state, federal, or local criminal justice agencies. I understand that I have the right to request, in writing, a complete and
accurate disclosure of the nature and scope of this investigation. I further understand that at any time during the course of my
volunteer service, Wake Forest Baptist Medical Center Volunteer Services, through its agent, Investigative Associates &
Consultants, Inc., in accordance with all applicable state and federal law, may obtain additional or supplemental investigative reports
to be used in connection with my retention as a volunteer at Wake Forest Baptist Medical Center Volunteer Services
. I understand
that the information requested below regarding sex, race, date of birth, and maiden name is for the sole purpose of gathering
information accurately.
Mo. Day Yr
Last First Middle Social Security # Date of Birth
(Please print Full Name – Do not use initials)
____ ______
Maiden, Previous Married, and all other Driver’s license # State Sex Race
Alias names used
_________________________________ __________________________________
Applicant’s Telephone Number Applicant’s email address
Yr Mo
Present Address City/State Zip/County How long?
List all other addresses used for the past 7 years - use additional page(s) if needed.
Yr Mo
Previous Address City/State Zip/County How long?
Yr Mo
Previous Address City/State Zip/County How long?
If you have lived in the following states within the last seven years; Alabama, Arkansas, District of Columbia, Idaho, Iowa,
Massachusetts, Minnesota, New Hampshire, New Jersey, South Dakota, or Virginia, you will be asked to complete an
additional form in order to complete your application.
If you have lived in Delaware, Nevada, Ohio, South Dakota, West Virginia or Wyoming, you will need to obtain the
appropriate fingerprint card(s) in order to complete your application.
A telephone facsimile or photographic copy of this authorization shall be as valid as the original.
If completed electronically, checking this box signifies an electronic signature.
Applicant’s Signature Date
After completing this form, please print, sign and either mail it to Volunteer Services at the address below or deliver it to our
office. The on-boarding process of your request to become a Wake Forest Baptist Health volunteer will not be completed until
our office has received this release and it has been returned from Investigative Associates.
Wake Forest Baptist Health
Volunteer Services
Main Floor, Ardmore Tower
Medical Center Boulevard
Winston-Salem, NC 27157
Office Hours: Monday - Friday 8:00am - 5:00pm
