Request for Adult Criminal History Information
The Limited Criminal History paperwork is needed to volunteer at school or on field trips.

When finished click SUBMIT at the bottom.

The Requesting AGENCY is Salk Elementary School at 3001 W. 77th Ave. Merrillville, IN 46410, phone 219-650-5304 sent to the ATTN: Karin Bown. There is no fee for the request PER IC 5-2-5-13 for a School Corporation, Non-Public School or Special Education Cooperative.
Adult Last Name *
Your answer
Adult First Name *
Your answer
Adult Middle Initial *
Your answer
Date of Birth *
adult date of birth
MM
/
DD
/
YYYY
Male or Female *
Required
Race of Adult *
Your answer
Student Name - First Child *
enter first child attending Jonas E. Salk Elementary
Your answer
Student Name - Second Child
enter second child - leave blank if none
Your answer
Student Name - Third Child
enter third child - leave blank if none
Your answer
Student Name - Fourth Child
enter fourth child - leave blank if none
Your answer
Teacher Name - First Child *
select classroom teacher for first child
Teacher Name - Second Child
Teacher Name - Third Child
Teacher Name - Fourth Child
Today's Date *
MM
/
DD
/
YYYY
WARNING PENALTY FOR MISUSE A non-criminal justice organization or individual receiving a limited criminal history may not utilize it for purposes other than those stated in the request or which deny the subject any civil right to which the subject is entitled. IC 5-2-5-5: Any person who uses limited criminal history for any purpose not specified in the request commits a Class A misdemeanor offense. I affirm, under penalty of perjury, that the Limited Criminal History Information requested will be used as specified.
Signature *
by entering your full name here, you are electronically signing this document.
Your answer
Submit
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