Dear Volunteer:

Thank you for your willingness to serve as a volunteer for Kokomo School Corporation. A volunteer with the Kokomo School Corporation is defined as an adult who will have care, custody, or control of one or more students on an independent and regular basis. Therefore, we ask that you complete the questions below to help us evaluate your suitability to work with these students. All volunteers are asked to provide us with this information; you are not being singled out for closer inspection. It is important that we provide a safe and secure environment for our students.

The conviction for a crime or any affirmative answer provided by you on this form is not an automatic bar to employment. The School District will consider the nature of any conviction or alleged conduct underlying the affirmative response, the date of the alleged conduct in question, your intervening conduct, and the relationship between the offense or alleged conduct underlying the affirmative response and the service for which you are volunteering.

* 1. 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 placed under court seal of security of moral turpitude?

* 2. 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?

* 3. 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?

* 4. AUTHORIZATION AND RELEASE

I authorize the School District to check my employment history including, without limitation, 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 or public employers or local, state, or federal agencies to provide the School District 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 EXPRESSLY WAIVE IN CONNECTION WITH ANY REQUEST FOR, OR PROVISION OF SUCH INFORMATION, ANY CLAIMS OR ACCUSES OF ACTION INCLUDING, WITHOUT LIMITATION, DEFAMATION, INFLICTION OF EMOTIONAL DISTRESS, INVASION OF PRIVACY, OR INTERFERENCE WITH CONTRACTUAL RELATIONS THAT I MIGHT OTHERWISE HAVE AGAINST THE SCHOOL DISTRICT, ITS OFFICIALS, EMPLOYEES, TRUSTEES OR AGENTS, OR AGAINST ANY PROVIDER OF SUCH INFORMATION.

I HAVE READ THIS AUTHORIZATION AND RELEASE OF ALL CLAIMS, AND I EXPRESSLY AGREE TO THE TERMS SET OUT HEREIN.

Do we have permission to check your Limited Criminal History?

* 5. What school building would you like to volunteer in?

* 6. How do you plan to volunteer?

* 7. What is your Social Security Number?

* 8. What is your first name? Please type your legal first name.

* 9. What is your middle initial?

* 10. What is your last name?

* 11. What is your street address?

* 12. What is your city, state, and zip code?

* 13. What is your date of birth?

* 14. Are you male or female?

* 15. What is your ethnic origin? (Optional)

* 16. What is your phone number including area code?

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