Please complete this form along with uploading a copy of your Driver’s License and/or Michigan ID card no later than 2 weeks before the event date. All fields are required by the Michigan State Police in order to process the record check. The Chippewa Valley Schools Human Resources office will submit this information through a secure web site operated by the Michigan State Police. You will be contacted by mail by Human Resources only if there are questions about the criminal record check. This form and the record check will be filed in a secure location in the Human Resources Department for the current school year only. It will be deleted at the end of the school year. Your cooperation with this process is appreciated as it assists us with assuring the safety and well being of all of our students.

PLEASE NOTE:
1. If you have been convicted of a “listed offense” as defined in section 2 of the Sex Offender Registration Act you are prohibited from volunteering at your child’s school.
2. All other Felony and Misdemeanor offenses will be subject to a targeted screen and you may be further questioned.
3. If you are convicted of a crime after filling out this form please notify the Human Resource Department at 586-723-2090. Do not contact the school building.

Thank you for your interest in serving as a volunteer with the Chippewa Valley Schools.

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* 1. First Name:

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* 2. Middle Name:

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* 3. Last Name:

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* 4. I hereby authorize by me typing my signature below that the Chippewa Valley Schools to request the Michigan State Police Central Records Division to release any information regarding criminal records I may have to the Chippewa Valley Schools.

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* 5. Date Signed:

Date

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* 6. Email Address:

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* 7. Gender:

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* 8. Date of Birth:

Date

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* 9. Race:

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* 10. Street Address:

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* 11. City:

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* 12. State:

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* 13. Zip: 

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* 14. Daytime Phone Number:

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* 15. A copy of your driver's license and/or Michigan ID Card must accompany this form.  Please attach a copy below. We cannot process your application without your ID being uploaded. Applications that are not complete, including ID upload, will be deleted. 

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