Background Check Form

Thank you for your interest in volunteering for Goshen Community Schools! We greatly appreciate your time and energy. The information that you provide on this form will be used to conduct a limited criminal history check (Goshen Community Schools School Board policy #4121), which is for the protection of our students.

* Indicates required field

I have offered my services as a volunteer to help Goshen Community Schools in the following areas: *

Limited Criminal History Check Information Needed:

Name (First, Middle Initial, Last) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Secondary Phone Number *

Email *

Gender *

Race *

Date of Birth *

Building Assigned for Volunteer Work *

I agree to abide by all relevant School Board policies and administrative guidelines while on duty for the Corporation. I understand that, although I am covered under the Corporation's liability insurance policy, I am not covered by its health insurance policy nor am I eligible for workers' compensation. Should I become ill or suffer and accident while doing volunteer work for the Corporation, I agree that I shall be responsible for any and all hospital and medical charges that may accrue.

I understand further that, as a volunteer, I am not in any manner considered an employee of the Corporation or entitled to any benefits provided to employees. I further release the Board from any and all liability for any damages, whatever their nature which may result as a consequence of my volunteer services.

For the protection of the children in the school, Goshen Schools is required by law to inquire of its staff members whether or not they have ever been convicted of a crime related to children. We would appreciate your cooperation by indicating that you have never been convicted of any of the following offenses: aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, aggravated menacing, abuse or neglect of a child, kidnapping, abduction, child stealing, criminal child enticement, rape, sexual battery, corruption of a minor, gross sexual imposition, importuning, voyeurism, public indecency, felonious sexual penetration, compelling prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity, pandering obscenity involving a minor, pandering sexually-oriented matter involving a minor, illegal use of a minor in nudity-oriented material or performance, endangering children, contributing to the delinquency of children, carrying concealed weapons, improperly discharging a firearm at or into a school or house, corrupting another with drugs, placing harmful objects in or adulterating food of confection.

Volunteer Signature *

Date *

Signature of School Personnel completing this report *

Submit