School Volunteer: Background & Criminal History Check

PAOLI COMMUNITY SCHOOL CORPORATION

School Volunteer: Criminal History Check

Submission of information on this form is completely voluntary, required only of those adults who wish to be considered to serve as a "volunteer" or "helper" near students or in the schools when under the supervision of a certified staff member and approved by the principal. Submission of this form, for those who choose to do so, requires you to submit accurate and complete information.

This form does not meet local or state requirements for any individual who is not under the constant and direct supervision of a certified staff member at all times when interacting with students. The Expanded Criminal History Check is required in that circumstance (Unpaid/paid substitute teachers, unpaid/paid coaches, unpaid/paid bus drivers, etc).

This form and page are secure (valid, trusted server certificate) as evidenced by the "s" shown in "https" in the URL address above. Connections are encrypted and authenticated using a strong protocol, a strong key exchange, and a strong cipher. All information submitted on this form shall be used for the purpose of criminal history checks only.

Please make a note of the relevant dates below in order to plan for your renewed submission form based upon the "Valid Until" date of your current/most recent submission.

SUBMITTED Criminal History Check	Valid Until
July 2024 - June 2025	December 31, 2026
July 2025 - June 2026	December 31, 2027
July 2026 - June 2027	December 31, 2028
July 2027-June 2028	December 31, 2029
July 2028-June 2029	December 31, 2030

Select "YES" or "NO" as it applies to you for each of the following*

Rows	YES	NO
I am a registered sex offender
I have been found to be a sexually violent predator under Indiana Code 35-38-1-7.5
Convicted or unresolved charge of child molesting
Convicted or unresolved charge of child exploitation
Convicted or unresolved charge of possession of child pornography
Convicted or unresolved charge of vicarious sexual gratification
Convicted or unresolved charge of performing sexual conduct in the presence of a minor
Convicted or unresolved charge of child solicitation
Convicted or unresolved charge of child seduction
Convicted or unresolved charge of sexual misconduct with a minor
Convicted or unresolved charge of attempt to commit any offense listed above
Convicted or unresolved charge of an offense substantially similar to an offense described above

Full Name*

First NameMiddle NameLast NameSuffix

Date of Birth*

MonthDayYear

Social Security Number*

Sex*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Email*

Read the following terms carefully before proceeding:

1. My signature below and submission of this form constitutes authorization to check all criminal history arrests, charges, convictions, pleas, and any related investigatory information possessed by an agency of law enforcement, local government, county government, state government or federal government.

2. My signature below and submission of this form further authorizes persons, agencies or entities contacted by Paoli Community School Corporation, or an agent gathering the above-referenced information on behalf of the school corporation, to fully provide any information on the matters set forth above.

3. My signature below and submission of this form indicates my choice to waive in connection with any request for or provision of such information, any claims, including and without limitation, defamation, emotional distress, invasion of privacy, or interference with contractual relations I might otherwise have against Paoli Community School Corporation, its agents and officials, or against any provider of such information.

Agreement to Terms*

I agree with all of the statements above and affirm the accuracy of all information submitted herein.

Signature*

Today's Date*

MonthDayYear

Only one criminal history check is required each year, even if volunteering in both schools. Provide the name and current grade level of each child for which you are a guardian (or for which you are a contact approved by a guardian).

Rows	Name	Grade Level (PK, K, 1, ...9, 10, ...)
Child #1
Child #2
Child #3
Child #4
Child #5
Child #6