Volunteer Consent Form

Lee County School District No. "1

VOLUNTEER BACKGROUND CHECK CONSENT FORM
At which school would you like to volunteer (ASLA or LHS)?
Name

First NameMiddle Name or InitialLast name
Maiden or other name(s) used on all other records of birth or records of residence.
SS#
Physical Address
City
State
Zip Code
Date of Birth

MonthDayYear
Date
Gender
Race
Contact Number
Have you ever been convicted or pleaded guilty before a court for any federal, state or municipal criminal offense (exclude minor traffic misdemeanors)? Please place an X next to your response:

If yes, please provide details of conviction:
Have you ever been convicted or pleaded guilty before a court for any federal, state or municipal criminal offense (exclude minor traffic misdemeanors)? Please place an X next to your response.

YESNO
If yes, please provide details of conviction:
State
City
County
Date of Offense

MonthDayYear
Date
I_____________________, am applying to volunteer with the Lee County School District. I give LCSD permission to use any information provided during the application process in performing the criminal history check. I have the right to review and challenge any negative information that would impact a decision to allow me to volunteer. I will have the opportunity to clear up any mistaken information within a reasonable time frame set by LCSD. Under the Fair Credit Reporting Act, I have been advised that upon request, I will be provided the name, address and telephone number of the reporting agency as well as the nature, substance and source of information.

I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS CONSENT FORM IS TRUE, CORRECT AND COMPLETE.

Please return this form to your school office or mail it to LCSD Central Office, ATTENTION: Superintendent's Office, 161 Walnut Street, Marianna, Arkansas 72360.
Please type your first and last name here.
Signature

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Lee County School District No. "1