Volunteer Personnel Info Sheet

BENTON COMMUNITY SCHOOL CORPORATION Volunteer Personnel Information Sheet

Please take a few minutes to complete the following questionnaire. The safety of the students in Benton Community School Corporation is a top priority. The district requires all prospective employees and volunteers to have a limited background check, which is completed by our administrative staff. The following information is required to process the limited background check. Thank you!!

Student Information:

Name

First NameLast Name

Classroom

Teacher

Parent/Adult Information (as it appears on driver's license or state/federal identification):

Name

First NameMiddle InitialLast Name

Married Name 1

Married Name 2

Maiden Name

Date of Birth

Date

Gender (Circle One):

Race (Check One)

Address

Phone:

Volunteer Activity:

School:

1.) Are you currently being investigated, or under procedure to consider your discharge for misconduct, by your present employer, or have you offered a resignation because of misconduct to your previous employer?

2.) Have you ever been reprimanded, disciplined, discharged for misconduct, or asked to resign for misconduct from a prior position?

3.) Have you ever resigned from a prior position without being asked, but under circumstances involving your employer's investigation of your sexual contact with another person, of your mishandling of funds, or of your criminal conduct?

4.) Have you ever been charged with or investigated for sexual abuse of another person?

5.) Have you ever been charged with, pleaded guilty to or "no contest" (nolo contendere) to, or been convicted of any crime involving sexual abuse of another person or any other crime of moral turpitude?

(Moral turpitude is an act of baseness, vileness, or depravity in the private or social duties which a person owes another member of society or society in general and which is contrary to the accepted rule of right and duty between persons, including, but not limited to, theft, attempted theft, murder, rape, swindling, and indecency with a minor.)

6. Have you (a) ever been convicted of a crime other than a minor traffic offense, (b) ever entered a plea of guilty, or a plea of "no contest" (nolo contendere), or (c) has any court deferred further proceedings without entering a finding of guilty and placed you on probation for any crime other than a minor traffic offense?

If you have answered yes to any of the previous questions please explain in detail including the date of the charge the entity having jurisdiction the court action the charged offense in question and the address of the court or entity involved (attach additional pages if necessary)

Signature of Volunteer

Date