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Become a Client

     To become a client of Interfaith Caregivers, we require two forms to be filled out: the Client Application form and the Background Check. 

     You can fill out the forms online (scroll down), print out the forms & mail them in, or stop into our office (2000 US HWY 8 Suite 1, St Croix Falls WI 54024.)

     REMINDER: You must fill out BOTH FORMS BELOW (Client Application AND Background Check) to receive services. 

Client Application

Personal Information

Birthday
Month
Day
Year
Multi-line address
Lives In
House
Apartment
Mobile Home
Assisted Living
We ask the questions below for allergy purposes:

Emergency Contact 1:

Emergency Contact 2:

Health

Check All That Apply
In the past twelve months, have you worried that your food would run out before you were able to afford more or get a ride to the grocery store/food pantry?
YES
NO

Services

Services Requested
Health concerns volunteers should be aware of?
Single choice
Man
Woman
Either

Interfaith Caregivers of Polk County will conduct a background check on all applicants. Interfaith reserves the right to refuse services to any applicant. Please be aware that clients must be able to get to and from, in and out, of a vehicle on their own.

I understand that Interfaith is an organization based on the good-will of dedicated volunteers, and that a match for service is not guaranteed, although Interfaith will diligently work on finding a volunteer for my specific needs. In addition, the information I have provided on this application is truthful and accurate to the best of my knowledge. After Interfaith receives your application, we will contact you with a few more questions, helping us understand how we can best provide service.

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Background Check

FAIR CREDIT REPORTING ACT (FCRA) DISCLOSURE

In considering you as a client or a volunteer and, if you are already a client or a volunteer, in considering you for subsequent promotion, assignment, reassignment, retention, discipline, or other purposes, Interfaith Caregivers of Polk County (“the Company”) may request and rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency.


For explanation purposes: a “consumer report” is a written, oral or other communication of any information by a consumer reporting agency bearing on your character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in making any decision about you. Such information may include, for example, criminal history reports, or driving records.


Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for a client or volunteer purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address, and telephone number of the consumer reporting agency, and a summary of your rights under the FCRA.

The consumer and/or investigative consumer report(s) will be obtained from:

Trusted Employees, 7900 W. 78th Street, #400, Minneapolis, MN 55439, (888) 389-4023. Trusted Employees’ information and privacy policy can be found at www.trustedemployees.com.

para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street NW, Washington, DC 20552

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street NW, Washington, DC 20552.


  • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

  • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

    • a person has taken adverse action against you because of information in your credit report;

    • you are the victim of identity theft and place a fraud alert in your file;

    • your file contains inaccurate information as a result of fraud;

    • you are on public assistance;

    • you are unemployed but expect to apply for employment within 60 days.

  • In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

  • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

  • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

  • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

  • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

  • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

  • You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

  • You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-567-8688.

  • The following FCRA right applies with respect to nationwide consumer reporting agencies:

CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE

You have a right to place a “security freeze” on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.


  • As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s credit file, a business is required to take steps to verify the consumer’s identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.

  • A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.

  • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

  • Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law.

AUTHORIZATION OF BACKGROUND INVESTIGATION

I have received, read, and understand:

  • The Disclosure of Background Investigation;

  • The federal governmental notice entitled, “A Summary of Your Rights Under the Fair Credit Reporting Act”;

  • The document entitled “Additional State Law Notices” (and if a California applicant, the Notice Regarding Background Investigation Pursuant to California Law).


My signature below indicates my authorization for Interfaith Caregivers of Polk Cty(“the Company”) to obtain consumer and/or investigative consumer reports about me from a consumer reporting agency in considering me as a client or a volunteer.


By signing below, I also acknowledge that the facsimile (FAX) or photocopy of this document shall be valid and accepted with the same authority as the original.

California, Minnesota, and Oklahoma Applicants/Employees Only: Please check this box if you would like a free copy of the consumer investigative or consumer report prepared on you?
Yes
No
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PERSONAL DATA NEEDED FOR BACKGROUND CHECK PLEASE COMPLETE

Multi-line address
Birthday
Month
Day
Year

     REMINDER: You must fill out BOTH FORMS BELOW (Client Application AND Background Check) to receive services. 

Interfaith Caregiver's logo of a white heart with orange beams coming from it inside a dark grey square.
Interfaith Caregivers
of Polk County

Mailing Address

PO Box 833

 St. Croix Falls, WI 54024

Office Location

2000 US Hwy 8, Suite 1

St. Croix Falls, WI 54024

Office Hours

Monday - Friday, 9AM - 4PM.

Our Mission

Connecting seniors and adults with disabilities to volunteers and services supporting independence and quality of life.

Contact

(715) 483-8500

info@interfaithpolk.org

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©2026 Interfaith Caregivers

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