Juneau Cooperative Preschool Background Check Form printable pdf download

Student Name:

2014-2015

Juneau Cooperative Preschool

Background Check Form

This form must be completed by each adult who will either act as a volunteer work parent or drive on field trips. PLEASE

NOTE: Our background check consists of a review of public records available through the Alaska Court System and the

Alaska Sex Offender Registry. Parents who have been convicted of any sex-related offense, or any crime of domestic

violence, may not volunteer in the classroom or drive students (other than your own) on field trips.

Name of child _________________________________________ Your relationship to child________________________

Your legal name ____________________________________________________________________________________

(First)

(Middle)

(Last)

Gender

Date of Birth _________________________________________

For the past ten years, list cities of residence and the years that you lived there (continue list on the back if needed):

City

State

Country

What years?

List any names you have used in the past and the years that you used them:

Former name

Used from when to when?

Answer Yes or No to each of the following questions. Have you ever:

1. Been arrested, adjudicated or convicted of any crime relating to or involving minor children?_____

2. Been found to have sexually abused or exploited or physically abused any child or adult:

A) in any court action or proceeding?_____

B) by a professional disciplinary or licensing board?_____

3. Been the subject of a mental health involuntary commitment proceeding?_____

4. Been denied a license to care for children or adults, or had a license suspended or rebuked?_____

5. Ever committed a criminal offense relating to or involving minor children?_____

I hereby certify and affirm under penalty of perjury that the above information is true and correct to the best of my knowledge. I

understand that fraud or misrepresentation in my answers can serve as the basis for excluding my participation in the Juneau

Cooperative Preschool.

I hereby authorize the Juneau Cooperative Preschool to use this form to obtain information about me from the Alaska Court System.

BY MY SIGNATURE BELOW, I HERBY CERTIFY THAT I UNDERSTAND THAT BEING UNDER THE INFLUENCE OF ALCOHOL OR ILLEGAL DRUGS

WHILE IN THE PRESENCE OF CHILDREN AT JUNEAU COOPERATIVE PRESCHOOL OR ANY JUNEAU COOPERATIVE PRESCHOOL FIELD TRIPS

OR SPONSORED ACTIVITIES WILL RESULT IN MY BEING EXCLUDED FROM FURTHER PARTICIPATION IN THE PROGRAM.

Signature___________________________________________________________ Date______________________________

Juneau Cooperative Preschool Background Check Form