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Consent Form to Obtain Conviction Criminal History File Searches

As a prospective volunteer, I understand that it is the policy of the Bentley Community School District to secure conviction criminal history information as part of their screening process using the information provided below. (This form has been developed for your safety and the safety of other volunteers and students involved with Bentley Community School District.)

Please print all information clearly:

Name _________________________________________________________________________________________

        Last                                        First                                        Middle                        

Address ________________________________________________________________________________________

Maiden Name/Names Used Previously ________________________________________________________________

Birth Date:  _____/_____/_____                Race:  _____________________                  Sex: ____________________

Phone Number: _____________________________________________

I understand that the above information is required by the sexual Offenders Registry list and Central Records Division of the Michigan State Police, Lansing, Michigan, and by the Federal Bureau of Investigation. I authorize Bentley Community School District to use the above information  for the sole purpose of obtaining conviction only criminal history file searches.

I understand that information gathered in these history files searches will be used by the Bentley Community School District in reaching voluntary status decisions. I hereby release all personas, institutions and organizations from any and all liability for damages of any kind, which may result because of compliance with this authorization and request to release information.

______________________________________________________________     _________________________________

Signature of Prospective Volunteer                                                Date

Building(s):      ⃣⃣⃣   Barhitte Elementary                  ⃣⃣   Middle School           ⃣⃣   High School

It is the policy of the Bentley Community Schools Board of Education that the Bentley Community School District will not discriminate in its educational programs and activities on the basis of age, race, creed, religion, color, national origin, sex, marital status, disability, or any other additional criteria identified by any applicable state or federal statute.

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