Screening Statement

GCCARD Head Start

Intern/Volunteer Screening Statement
Adult First Name*
Intern/Volunteer/Parent/Grandparent/etc. First Name
Adult Last Name*
Intern/Volunteer/Parent/Grandparent/etc. Last Name
Select Center(s) / Classroom(s)*
**Ask Teacher if Uncertain**
Child's Name(s)
Leave Blank if Not Applicable
I certify the following:
- I am aware that abuse and neglect of children is against the law.
- I have been informed of the GCCARD Head Start policies on child abuse and neglect.
- I understand that, as an intern/volunteer, I am mandated by law to report abuse and neglect of children to Child Protective Services at the Michigan Department of Human Services within 24 hours.
By signing this statement, I give permission to GCCARD Head Start to complete a background check on me through the Michigan Public Sex Offender Registry in compliance with Child Licensing Regulations regarding supervised volunteers. I understand that any individual registered on the public sex offender registry will be prohibited from having contact with any child in care.
Signature*

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GCCARD Head Start