Volunteer Background Check Question Title * 1. What is your first name? Please type your legal first name. Question Title * 2. What is your middle initial? Question Title * 3. What is your last name? Question Title * 4. What is your Social Security Number? Including slashes (000-00-0000)(Not used for any other purpose) Question Title * 5. What is your date of birth? (ex. 01/01/1999) Date / Time Date Question Title * 6. What is your gender? Question Title * 7. What is your ethnic origin? (Optional) White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Question Title * 8. What is your street address? Question Title * 9. What is your city, state, and zip code? Question Title * 10. What is your phone number including area code? (000-000-0000) Question Title * 11. Have you ever been investigated for, charged with, or pled guilty or "no contest" to any crime involving the sexual abuse of any person or indecency with a minor that has not been expunged by the court or place under court seal of security of moral turpitude? Yes No Question Title * 12. Have you ever been charged with a crime, other than a minor traffic offense, where the court has deferred further proceedings without entering a finding of guilt and placed you on probation or in a public service or education program that has not been expunged by the court or placed under court seal of security of moral turpitude? Yes No Question Title * 13. Have you ever pled guilty, been convicted of or otherwise been found in violation of the law by a court for any matter other than a minor traffic violation that has not been expunged by the court or placed under court seal of security of moral turpitude? Yes No Question Title * 14. What school building would you like to volunteer in? Question Title * 15. What event or field trip are you planning to volunteer for? Question Title * 16. AUTHORIZATION & RELEASE I authorize the Kokomo School Corporation to check my employment history including, without investigation, reference checks, and to seek the release of investigatory information, including a "limited criminal history", possessed by any private or public employer or any local, state or federal agency. I authorize these private public employers or local , state, or federal agencies to provide Kokomo School Corporation any information they may release concerning the matters described herein, and I will cooperate to the extent necessary to obtain the release of this information. I EXPRESS WAIVE IN CONNECTION WITH ANY REQUEST, ANY CLAIMS OR ACCUSES OF ACTION INCLUDING, WITHOUT LIMITATION, DEFAMATION, INVASION OF PRIVACY, OR INTERFERENCE WITH CONTRACTUAL RELATIONS THAT I MIGHT OTHERWISE HAVE AGAINST KOKOMO SCHOOL CORPORATION, ITS OFFICIALS, EMPLOYEES, TRUSTEES OR AGENTS, OR AGAINST ANY PROVIDER OF SUCH INFORMATION. I HAVE READ THIS AUTHORIZATION AND AGREE TO THESE TERMS SET OUT HERIN. Do we have permission to check your Limited Criminal History? Yes No Submit