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CRIMINAL HISTORY RECORD/SEX OFFENDERS REGISTRY CONSENT FORM
As a prospective volunteer of Muskegon Public Schools, I understand that it is this Public School’s policy to secure criminal history information as part of their volunteer screening process using the information provided below.
Identification
Legal Name
*
First Name
Middle Name
Last Name
List all previous names: (Maiden, previous married names, etc.)
Date of Birth
*
-
Month
-
Day
Year
Date
Race
*
Please Select
Black
White
Asian/Pacific Islander
American Indian/Alaskan Native
Gender
*
Male
Female
Unknown
Driver’s License/State ID #
*
Please take a photo of your Driver's License/State ID for identificaiton purposes.
*
Contact Information
Email
*
example@example.com
Best Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Is this Application
*
New
Renewal
Do you have physical limitations?
*
Yes
No
Please explain
Emergency Contact Name
*
Phone Number
*
Please enter a valid phone number.
Please select your relationship to our distrcit
*
Please Select
Parent/Guardian of a student
Grandparent of a student
Relative of a student
Community Member
Outside Agency
Alumni
Student(s) who attend MPS
Perferred Building
*
Bunker
Glenside
Marquette
Oakview
Muskegon Middle
Muskegon High School
MCEC
No Preference
Contact Main Office
Please Select
Bunker main office 231-720-2300
Glenside main office 231-720-2200
Marquette main office 231-720-2600
Oakview main office 231-720-2450
CHMS main office 231-720-3000
MCEC main office 231-720-2540
MHS main office 231-720-2800
Secretary email
Please Select
smcbride@mpsk12.net
vtartt@mpsk12.net
smcbride@mpsk12.net
twillia3@mpsk12.net
kstimac@mpsk12.net
ageren@mpsk12.net
asantos@mpsk12.net
lkeeney@mpsk12.net
mlang@mpsk12.net
Are you a Muskegon Public Schools alumni?
*
Yes
No
In what areas are you interested in volunteering? Please check the boxes you would like to be contacted about.
*
Class/Building Parties, Events & Fieldtrips
Athletic Events/Consessions/Coaching
Tutoring mentoring 1-on-1 with students
Volunteer Group/Outside Agency
Other
Self Disclosure Information
Have you ever been: convicted of a felony, a registered sex offender; previously denied MPS volunteer opportunity; involved in CPS investigation; or have criminal charges pending? A yes response does not automatically disqualify you from volunteering
Yes
No
If yes, please provide details and dates
Disclaimer
I understand I will not be reimbursed or paid for my time as a volunteer with Muskegon Public Schools. As a volunteer I agree to indemnify, defend and hold harmless the District, its officers, employees, agents, board members, students and guests from all claims, damages and liabilities arising out of a volunteer's volunteer services. Volunteer is responsible for all injuries or damages to persons or property caused by volunteers. If request is approved volunteer certifies that when serving in the volunteer position s/he will (i)perform as a volunteer and not a District employee, (ii) comply with all Federal, State and local laws, rules and regulations, (iii) comply with any additional requirements or conditions that may be imposed by the superintendent; and (iv) not use or be under the influence of illegal drugs, alcohol or other mind altering substances. Volunteers acknowledge that volunteering is a privilege and not a right. The District or designee may reject a person's request or terminate a volunteer assignment at any time for any reason that is not unlawful. Volunteers acknowledge that by providing the above information they are consenting to the District obtaining an iChat background check and confirm that, to the best of their knowledge, the information provided is true, complete and accurate
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: