First Name *

Middle Name *

Last Name *

Email address *

Phone Number *

Date of Birth *

Race *

Gender *

Driver's license or State ID number *

Other First name

Other Middle name

Other Last name

Building(s)/activity you are wishing to volunteer at (select all)

Pursuant to Public Act 68 of 1993 and Public Act 83 of 1995, please answer the following questions: 1) Have you ever plead guilty, or been convicted of a felony in a state or federal court? If yes, please provide a detailed description of the conviction: *

2) Have you ever pled guilty, or been convicted of a misdemeanor in a state or federal court? If yes, please provide the date and state offense/conviction occurred and a detailed description of the conviction. *

3) Are you the subject of a current criminal investigation or have pending charges against you? If yes, please provide a detailed description of the investigation or pending charges: *

I understand Kearsley Community Schools is requesting this information as part of the screening process for potential volunteers and the results will be kept confidential. The personal information included on this form is required in order to process a criminal history background check by the Central Records Division of the Michigan State Police. By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *