CSCSHC School Volunteers - Information and Authorization Form
One of the goals of the Community School Corporation of Southern Hancock County is to provide the safest environment possible for all students. At the same time, the district recognizes the value of volunteers in the daily operations of the school system. In keeping with this goal, it is our practice to obtain criminal history background checks on all school volunteers, including field trip chaperones.

Please provide the information below. In the case of field trip chaperones, the form must be completed at least three weeks prior to the scheduled field trip. This information form will be valid for the current school year.

Please note: In the event that the State Police service is unable to return results due to common name or other reason, you will be asked to complete a ‘Volunteer Background Check’ through our online vendor, Safe Hiring Solutions. You would complete this process online, and pay the minimum $12.95 fee on their website directly. The school secretary will notify you if this process is necessary.

Legal Last Name
Your answer
Legal First Name
Your answer
Legal Middle Initial
Your answer
Email Address
Your answer
Street Address
Your answer
City
Your answer
State
Your answer
Zipcode
Your answer
Home Phone
###-###-####
Your answer
Work Phone
###-###-####
Your answer
Birth Date
MM
/
DD
/
YYYY
Race
Sex
Birthplace
City, State
Your answer
I wish to be added to the chaperone/volunteer list for Brandywine Elementary School
Select all that apply
I wish to be added to the chaperone/volunteer list for New Palestine Elementary School
Select all that apply
I wish to be added to the chaperone/volunteer list for Sugar Creek Elementary School
Select all that apply
I wish to be added to the chaperone/volunteer list for Doe Creek Middle School
Select all that apply
I wish to be added to the chaperone/volunteer list for New Palestine High School
Select all that apply
Student Name(s)
Please list each student's first and last names, separating each with commas (Ex: Joe Smith, Sally Smith, Susie Smith)
Your answer
Authorization and Release
I agree to abide by all relevant School Board policies and administrative guidelines while on duty for the School Corporation. I understand that, although I am covered under the School Corporation's liability insurance policy, I am not covered by its health insurance policy nor am I eligible for workers' compensation. Should I become ill or suffer an accident while doing volunteer work for the School Corporation, I agree that I shall be responsible for any and all hospital and medical charges that may accrue. I understand further that, as a volunteer, I am not in any manner considered an employee of the School Corporation or entitled to any benefits provided to employees. I further release the Board from any and all liability for any damages, whatever their nature, which may result as a consequence of my volunteer services. For the protection of the children in the school, the School Corporation is required by law to inquire of its staff members whether or not they have ever been convicted of a crime related to children. We would appreciate your cooperation by indicating that you have never been convicted of any of the following offenses: aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, aggravated menacing, abuse or neglect of a child, kidnapping, abduction, child stealing, criminal child enticement, rape, sexual battery, corruption of a minor, gross sexual imposition, importuning, voyeurism, public indecency, felonious sexual penetration, compelling prostitution, promoting prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity, pandering obscenity involving a minor, pandering sexually-oriented matter involving a minor, illegal use of a minor in nudity-oriented material or performance, endangering children, contributing to the delinquency of children, carrying concealed weapons, improperly discharging a firearm at or into a school or house, corrupting another with drugs, placing harmful objects in or adulterating food or confection. You will also be expected to submit a criminal background check as required by Board policy and Indiana law. As a volunteer for Southern Hancock Schools, I verify that I have not been convicted of any of the above offenses. I authorize the school corporation to obtain my current criminal history information. I understand that the criminal history check must be completed prior to volunteering. In order to participate in field trips, volunteers/chaperones must complete and submit the form to the building principal at least three weeks prior to the scheduled field trip.
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