Office of Safety & Security Volunteer Release Form

Office of Safety & Security Volunteer Release Form
APS/Partner School Administrator’s Name*
Title*
Phone Number
Email Address*
example@example.com
APS Department (if applicable)
School Location/Volunteer Site*
Prospective Volunteer Last Name*
Prospective Volunteer First Name*
Prospective Volunteer Middle Initial
Current Address*
City*
State*
Zip Code*
Date of Birth*

MonthDayYear
Date
Country of Birth*
State of Birth*
Social Security Number*
Race/Ethnicity*
Gender:

MaleFemale
Phone Number*
Email Address*
example@example.com
Organization / Volunteer Program*
APS Student Relative/Family Member

Check the box if you are currently an:APS EmployeeAPS Parent/Guardian

If yes, please list schools, grades, and student names:

	School Name	Grade	Student Name

Office of Safety & Security Criminal Background Check Personal Affirmation
Statement of Personal Affirmation:
Check the appropriate box for each question. If you answer “YES” to any question, an explanation and supporting documentation – including any final court disposition documents – may be requested. Documents MUST be submitted within five (5) business days of the request. All responses must be completely truthful.
NoYes
2. Have you been convicted of a felony or misdemeanor, or pled nolo contendere or first offender, or are you now
NoYes
3. “Driving Under the Influence” (DUI) of alcohol or other drugs and “Driving While Impaired” (DWI) offenses MUST be reported. Have you been convicted of a felony or misdemeanor, or pled nolo contendere or first offender, or are you now under investigation for DUI or DWI? Please respond accurately even if you have been
YesNo
Statement of Consent:
This section is to be completed by the Volunteer. Please print all information clearly.
I, LAST NAME *
FIRST NAME *
MIDDLE INITIAL
have applied to be a volunteer within Atlanta Public Schools (APS This form provides consent to conduct fingerprinting and/or a criminal background records check by the Atlanta Public Schools – Office of Safety & Security. I also authorize the release of such information to the Atlanta Public Schools now and at any time during service, and release, discharge, and waive any and all claims, which may arise against me for the release of accurate information.

I authorize APS to receive any criminal or driver’s history records information pertaining to me, which may be on file in any state or local criminal justice agency. I further give consent to APS to have my fingerprints taken as part of the volunteer process and perform periodic criminal history background checks for the duration of my service or affiliation with the Atlanta Public Schools.

I understand that the Georgia Criminal Information Center (GCIC), APS employees, nor any other agency or employees of the State of Georgia shall be responsible for the accuracy of information nor have any liability for defamation, invasion of privacy, negligence or any other claim in connection with any dissemination of information pursuant to this fingerprinting and criminal background record check and shall be immune from suit based upon any such claims.

In this application, I have provided accurate information to the best of my ability. I have received the training required for my volunteer position, and I understand and will comply with the expectations of volunteers in the Atlanta Public Schools described in regulation GAK(1)-R(1) School Volunteers. I also understand that Atlanta Public Schools reserves the right to refuse the services offered by any volunteer.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
Please upload a copy of your Driver's License or Identification*

Cancelof
Should be Empty:

Office of Safety & Security Volunteer Release Form

Office of Safety & Security Criminal Background Check Personal Affirmation

Statement of Personal Affirmation:

Statement of Consent: