Disclosure Notice And Authorization Background Reports Form printable pdf download

Disclosure Notice And Authorization Background Reports Form

Midlothian Independent School District

DISCLOSURE NOTICE AND AUTHORIZATION BACKGROUND REPORTS

Only one form needed for submission per school year for each volunteer/employee. This form

must be completed by all individuals that will be in contact with students during the year at

events such as, but not limited to: field trips, parties, field days, volunteering, etc.

Important: Please read carefully before signing.

The Midlothian Independent School District may obtain from any law enforcement or criminal justice

agency all criminal history information that relates to:

A person the District intends to employ in any capacity;

A person who has indicated, in writing, an intention to serve as a volunteer with the

District; or

A volunteer or employee of the District.

Criminal history record information regarding a person who is a volunteer or employee of the District

may be obtained no more than twice each year.

Education Code 22.0833(a), (c); Gov’t Code 411.097 (b)

AUTHORIZATION

You hereby authorize and request, without any reservation, any reporting agency, police department, law

enforcement agency, or division of motor vehicles, having knowledge about you to furnish Midlothian

ISD with any and all police/criminal history information in their possession regarding you, in order that

your employment may be evaluated.

READ, ACKNOWLEDGED AND AUTHORIZED

Volunteer/Employee Information:

____________________________________

___________________________

Signature

Date

LAST NAME: ________________________

FIRST NAME:________________________

MIDDLE NAME:______________________

DATE OF BIRTH: _____________________

RACE: _______________________________

GENDER: __________

DRIVER LICENSE #: ___________________

DL STATE_________

STUDENT’S NAME ___________________________

CAMPUS(ES) ___________________

___________________

-------------------------------------------- FOR OFFICE USE ONLY -------------------------------------------------

VERIFICATION DATE_________

_______APPROVED

________DENIED

7/01/2009

Disclosure Notice And Authorization Background Reports Form