Limited Background Check 2020-2021
EASTBROOK COMMUNITY SCHOOLS CORPORATION

AGREEMENT TO LIMITED CRIMINAL HISTORY CHECK AND WAIVER OF ALL CLAIMS

YOU DO NOT NEED MULTIPLE FORMS. ONLY ONE FORM PER PERSON IS NEEDED PER EACH SCHOOL YEAR - EVEN IF YOU HAVE STUDENTS IN OTHER BUILDINGS.

Comes now the Undersigned, and acknowledges that:

1. The Undersigned has volunteered services with Eastbrook Community Schools Corporation which involve contact with, care of, or supervision over a child who is being placed, matched, or monitored by a not-for-profit corporation.
2. As a part of the Eastbrook Community Schools Safety and Security Policies, the Undersigned acknowledges, understands, and consents to Eastbrook Community Schools Corporation obtaining his or her limited criminal history information as set forth in Indiana Code 10-13-3 and 5-2-12, et al. The school corporation may require the Undersigned to provide a set of fingerprints for this purpose.
3. The Undersigned hereby agrees to provide and does provide a written consent for the school corporation to request under IC 10-13-3 limited criminal history information or national criminal history background check concerning the Undersigned before or not later than three months after the Undersigned’s volunteer work with the corporation. If the Undersigned has previously done volunteer work, Eastbrook may obtain the information at this time under this new policy. The Undersigned acknowledges that he or she is obligated to provide documentation for any criminal disposition as set forth in Indiana Code 10-13-3-7 that does not appear on the criminal history, except for a crime that has been expunged by a court or placed under seal.
4. The limited criminal history information shall be kept confidential, and may be used by the school corporation only for the purpose of denying the right of the Undersigned to perform volunteer work for the school corporation, or to be employed by the school corporation.
5. The Undersigned has read and understands the above, and hereby consents to Eastbrook Community Schools Corporation obtaining the limited criminal history information as set forth above, and waives any claim he or she might have against the school corporation concerning such obtaining or use of this information.

THIS FORM TO BE USED FOR ONE PERSON ONLY –FOR OTHER VOLUNTEERS USE A SEPARATE FORM
Volunteer First Name (legal) *
Volunteer Middle Initial (legal) *
Volunteer Last Name (legal) *
Electronic Signature (type full legal name) *
I agree that by typing my name on the signature line, I consent electronically to the limited criminal history check described above and the terms, conditions and waiver set forth above.
Volunteer's Date of Birth *
MM
/
DD
/
YYYY
Race *
Sex *
Volunteering for (Student Names: If more than one student in corporation please list all students) *
Check all that apply *
Required
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