Middlebury Community Schools

CONSENT TO PERFORM NON-EMPLOYMENT BACKGROUND CHECK FOR VOLUNTEERING ACTIVITIES

Please complete only one form for the corporation.  New form required EACH school year.

                           

** TO BE USED FOR NON-EMPLOYMENT BACKGROUND CHECK PURPOSES ONLY

Are you an employee of Middlebury Community Schools?     

In connection with my application and desire to engage in volunteer activities, I have been advised and I hereby consent and authorize Middlebury Community Schools and its agent, at the time subsequent to my application process, to conduct a background check that will include a criminal record check. I do hereby consent to Middlebury Community School's use of any information provided on this form in performing the non-employment related background check.  I agree to release, indemnify and hold harmless Middlebury Community Schools and any agency used by Middlebury Community Schools with regard to any information provided by the agency.  I have been informed that I will have a reasonable opportunity to clear up any mistaken information provided by the agency within a reasonable time frame established within the sole discretion of Middlebury Community Schools.  I acknowledge that facsimile, copy or electronic version of this form shall be as valid as the original.

The following are my responses to questions about my criminal history (if any).

  1. Have you ever been arrested for or convicted of a crime that has not been expunged by a court?

    If yes, please provide details below.


  2. Have you ever received deferred adjudication or similar disposition for any non-expunged offense?

    If yes, please provide details below.


  3. Have you ever received probation or community supervision for any non-expunged offense?

    If yes, please provide details below.


  4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?

    If yes, please provide details below.


  5. As of the date of this consent form, do you have any pending charges against you?

    If yes, please provide details below.


THIS SECTION IS TO BE USED TO LIST ALL COUNTIES AND STATES OF RESIDENCE SINCE HIGH SCHOOL GRADUATION OR AGE 18.

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I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS CONSENT FORM IS TRUE, CORRECT AND COMPLETE.  IF ANY INFORMATION PROVES TO BE INCORRECT OR INCOMPLETE, I UNDERSTAND THAT THIS WILL BE GROUNDS FOR DENYING OR TERMINATING MY ABILITY TO PROVIDE VOLUNTEER SERVICES FOR Middlebury Community Schools.

Signed this 16th day of September, 2021.