MSD of Wayne Township
Background History Application
For Contractor type company name
School (Choose all that apply)
Adult Basic Education
Ben Davis High School
Ben Davis Ninth Grade Center
Ben Davis University High School
Chapel Glen Elementary
Chapel Hill 7th & 8th Grade Center
Garden City Elementary
Lynhurst 7th & 8th Grade Center
North Wayne Elementary
Stout Field Elementary
Wayne Preparatory Academy
Wayne Township Preschool
Name (First, Middle, Last)
Address ( number, street, city, state, zip code)
Date of birth ( MM/DD/YYYY) *If under 18 years of age, criminal history must be obtained from the Indiana Government Center (317-233-0800).
Social Security Number
Any other names I have been known by:
American Indian/Alaskan Native
Alternate Phone Number
1. Are you a U.S. citizen or do you have the legal right to remain permanently in USA?
2. Are you aware as to whether your conduct as an employee or the quality of your work is the focus of any investigation by your current employer? If yes, explain the circumstances.
Not Presently Employed
2. If yes, explain the circumstances.
The conviction of a crime or any affirmative answer provided by you is not an automatic bar to volunteering or employment. The school district will consider the nature of any conviction or alleged conduct underlying the affirmative response, the date of alleged conduct in question, your intervening conduct, and the relationship between the offense or alleged conduct and the position for which you are applying. Have you ever been convicted of or had prosecution deferred on a crime, that has not been expunged by a court, related to any of the following: sexual contact with another person; sexual abuse; sexual misconduct; child abuse; battery; theft of or taking property; mishandling funds; fraud, forgery; the use, sale or possession of controlled substances or alcohol; or intoxication? If yes, explain the circumstances below.
3. If yes, explain circumstances. Please include: the matter for which you were investigated; a description of any underlying incidents or events; the date and nature of the investigation; the date and nature of disposition of the investigation; and any other information which you want to provide concerning the matter.
4. Have you ever been investigated for, charged with, or pleaded guilty or "no contest" to any crime, that has not been expunged by a court, involving the sexual abuse of any person or indecency with a minor? If yes, explain the circumstances below.
4. If yes, please explain circumstances.
5. Have you ever been an employee of the MSD of Wayne Township previously?
5. If yes, what dates?
In the event of employment, I understand that false or misleading information given in my application or interview(s) or any omission of information may result in discharge.
I attest that I will abide by all School Board policies and District guidelines, and the following School Board policies:
- Non-Discrimination and Merit-Based Decision Making
- Responsible Use of Technology
- Employee Attendance
- Duties Related to Arrests or Criminal Charges
- Possession of Firearms or Other Dangerous Weapons
- No Tobacco
- Hazing, Discrimination, Harassment, Intimidation, Provocation
- Drugs and Alcohol
I understand, also, that I am required to abide by all other rules and regulations of the MSD of Wayne Township. A complete list of these rules and regulations can be found at: www.wayne.k12.in.us/district/school-board.asp
I completely and forever release MSD Wayne and its present and future directors, officers, employees, agents, attorneys, volunteers, servants, representatives, predecessors and successors in interest, assigns, and all other person, firms, or corporations with whom any of the former have been, are now, or may hereafter be affiliated from any and all liability for and waive any and all claims, actions, lawsuits, demands, grievances, charges, rights, damages, costs, legal fees, losses of service, or expenses for injury, loss, or damage in any way connected with my participation in the programs of MSD Wayne, whether or not caused in the whole or part by the negligence of MSD of Wayne or any of the individuals mentioned above. This release and waiver shall also apply to my family members, legal representative, heirs, assigns, successors, or any other person or organization connected to me. I understand MSD of Wayne does not provide any type of health insurance nor am I eligible for worker's compensation claims. As required by School Board policy, I will report an arrests, the filing of criminal charges, convictions for a crime, or any substantiated report of child abuse or neglect for which I am the subject while serving as a volunteer or employed by MSD Wayne.
A Criminal Background check may be initiated annually if applicable.
By signing below, I hereby voluntarily authorize MSD of Wayne Township to obtain a criminal history report about me from a criminal history reporting agency and to consider this information when making decisions regarding my employment, continued employment, or volunteer status at MSD of Wayne Township. I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty or perjury and false swearing that my answers are correct and complete to the best of my knowledge.
By checking this box I am electronically signing this application.
An approved background application will remain of file and active for a period of two (2) years. *
*Background applications for Wayne Township Pre-School remain on file and active for one (1) year.
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