Student Data Sheet Template (Page 3 of 3) in pdf

Student Data Sheet Template Page 3

This information is required to conduct a criminal background check:

Social Security #: __________________________ Date of Birth (mm/dd/yyyy): __________________

Have you ever been convicted of a crime for any offense or violation other than minor traffic

violations?

Yes

Date: _____________

Where: __________________________________

Explain: ______________________________________________________________________

_____________________________________________________________________________

By signing this document you are confirming that all information contained in this application is

true and correct to the best of your knowledge and belief. You are also confirming that you are

not and have not been a client of Sojourner Family Peace Center at any time during the last 12

months.

Signature: ____________________________________

Date: __________________________

Completion of this form does not guarantee an applicant status or placement as a volunteer

with Sojourner Family Peace Center (SFPC). SFPC accepts applications for volunteer service

with the understanding that volunteer service is at the sole discretion of the agency. SFPC

reserves the right to make decisions regarding volunteer service on a case by case basis and

may decide to turn away a volunteer applicant or terminate a volunteer’s service with the

agency at any time, for whatever reason.

PLEASE RETURN FORM TO:

Sojourner Family Peace Center

Attn: Lianne Wiggins

P.O. Box 080319

Milwaukee, WI 53208-8000

FORM595B - Student Data Sheet

(3,3)

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Student Data Sheet Template Page 3