Consent For Background Check Form
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1CONSENT FOR BACKGROUND CHECK
In order to provide a safe environment for our students, we reserve the right to check references and review relevant
public documents regarding criminal activity of any volunteer who may have contact with our students. For this reason,
please provide information as requested below:
If additional space is required to provide information, please use reverse side of form.
Name:___________________________________________________________________________________________
Last
First
Middle
Maiden Name
Former Name(s):___________________________________________________________________________________
Current Address:___________________________________________________________________________________
Street
City
State
Zip
Previous Address:__________________________________________________________________________________
Street
City
State
Zip
(within last 10 years)
Previous Address:__________________________________________________________________________________
Street
City
State
Zip
(within last 10 years)
Address of residency outside of Wisconsin_______________________________________________________________
Street
City
State
Zip
(if applicable)
Date of Birth:____________________
Gender:________________ Social Security Number:_____________________
Driver’s License Number:____________________________________________________________________________
Please disclose any convictions for criminal activity or ordinance violations*:
Date:
Place:
Nature of Conviction:
Sentence:
_____________
_________________
_______________________
___________________
_____________
_________________
_______________________
___________________
_____________
_________________
_______________________
___________________
Please note: Pending charges or past convictions are not an automatic bar to participation but will be considered to the extend they bear a substantial
relationship to the position.
I authorize the Brown County Children with Disabilities Education Board in De Pere, Wisconsin, to make any inquiry of or receive any information from
any person or organization regarding my suitability for myself to act as a volunteer and do hereby expressly give permission to these persons or
organizations to provide such information. Such inquiries may include, but are not limited to, the verification of any information set forth in this
application, the quality and quantity of my work, my work history and medical records, and my character, qualifications, and background. In
consideration for the cooperation extended to the Brown County Children with Disabilities Education Board by release of such information. I give this
waiver, release, and covenant not to sue for myself, my heirs, assigns and successors in interest forever. I do so understanding that the information
obtained may be such as to disqualify me for participation, result in rejection of my application, or my dismissal from involvement with the Syble Hopp
School. I understand that such information is sought with confidentiality, and I will not request copies thereof. I certify that all information provided
herein is accurate to the best of my knowledge, information and belief, and I acknowledge that any false statements, incomplete statements, or
misrepresentations may subject me to disqualification, rejection, or dismissal at any time. A copy of this authorization shall be effective as the original
for the purposes stated above. I understand and agree that participation is for no definite period and may be terminated at any time without prior notice
and without cause. I understand that I may be required to undergo drug testing. I further understand that any acceptance of my offer to volunteer may
also be conditioned upon the results of a physical examination. I HAVE READ AND UNDERSTAND THE FOREGOING CERTIFICATION, AND SIGN
BELOW VOLUNTARILY AND WITH KNOWLEDGE OF ITS CONTENTS.
Signature:_______________________________________________________________________________ Date:____________________________
This form is maintained from the application and is used only for background check. The Brown County Children with Disabilities Education Board is an
equal opportunity employer and adheres to the Title IX regulations and section 504 of the Vocational Rehabilitation Act of 1972.
For definition, conviction for criminal activity includes all convictions for misdemeanors or felonies, including deferred judgment agreements and
convictions in jurisdictions other than the State of Wisconsin. Ordinance violations, include but are not limited to disorderly conduct violations, traffic
violations and all other municipal offence whether committed in the State of Wisconsin or otherwise. [10/06]
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