Volunteer Background Check Question Title * 1. What is your legal name? Including middle initial, if applicable. (Ex: Jonathan T. Smith) Question Title * 2. What is your familiar name? (Ex: John Smith) Question Title * 3. What is your Full Social Security Number? (Ex. 123-45-6789)Note: This is for identification purpose only and will not be disclosed for any other reason. Question Title * 4. What is your date of birth? Date: Date Question Title * 5. What is your gender? Female Male Question Title * 6. What is your ethnic origin? 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 Question Title * 7. What is your street address? Question Title * 8. What is your city, state, and zip code? (Ex. Kokomo, In. 46901) Question Title * 9. What is your phone number including area code? (Ex. 765-123-4567) Question Title * 10. Have you ever been convicted of, plead guilty, or otherwise been found in violation of the law? Yes No Question Title * 11. Have you ever been investigated for, charged with, or plead guilty or "no contest" to any crime involving the sexual abuse of any person or indecency with a minor? Yes No Question Title * 12. Have you ever been charged with a crime, 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? Yes No Question Title * 13. At what school(s) would you like to volunteer? Bon Air Elementary School Bon Air Middle School Boulevard Elementary School Central Middle School Darrough Chapel/ Peru Head Start Elwood Haynes Elementary School Kokomo Area Career Center Kokomo High School Lafayette Park Elementary School Maple Crest Elementary School Maple Crest Middle School McKinley School Pettit Park Elementary School Sycamore Elementary School Wallace Elementary School Question Title * 14. For what event or field trip are you planning to volunteer? (Ex. Class trip (list where) or volunteering in class)Note: If this is an out of state and/or overnight field trip, an Extensive Background Check is required. Question Title * 15. 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