Background Check Form • Liberty Christian School

BACKGROUND CHECK FOR VOLUNTEER PARTNERS

To provide for the safety of and godly examples to our students, Liberty Christian School requires all volunteers (including but not limited to classroom volunteers, field trip chaperones, volunteer drivers or volunteer coaches) to submit to a background investigation at the school’s expense before supervising or working directly with students. The Criminal Records Section of the Indiana State Police performs the criminal background check.

Our school also requires a driver’s record check for anyone offering to be a volunteer driver. Please complete the “Criminal History Affidavit” below and sign the authorization for the school to perform a criminal background check.

For those volunteering to serve as a driver, please go to the BMV website, https://secure.in.gov/BMV/mybmv/Default.aspx?ReturnUrl=%2fBMV%2fmybmv%2fMyDriver%2fDriverRecord.aspx, print a free copy of your driving record, and attach it to this affidavit. Your written application remains on file and is valid from year to year. However, the criminal history affidavit, the limited criminal history check, and (if applicable) the driver’s record review must be updated annually.

Criminal History Affidavit and Authorization to Conduct a Limited Criminal History Background Check

Checkboxes

1. I affirm that I am not now, and have never been,
a. Found by any court, including a military tribunal, to be a “sex offender” as defined by Indiana Code 11-8-8-4.5 . [available for review online at http://www.in.gov/legislative/ic/2010/title11/ar8/ch8.pdf]
b. Required to register as a sex offender in any state.
c. Adjudicated as a juvenile for an act that would be a sex offense, as defined by Indiana Code 11-8-8-4.5, if the act were committed by an adult.

Checkboxes (copy)

2. I also affirm that I have never been charged with any of the crimes noted above and later had the charge reduced by negotiation to a conviction for an offense not listed in Indiana Code 11-8- 8-4.5.

Finally, I affirm (Check the applicable box)

that I have no criminal convictions or pending charges; or
that at least one (1) year has passed after I successfully completed a sentence for a misdemeanor offense; or
that at least two (2) years have passed after I successfully completed a sentence for a Class D/ Level 6 Felony offense; or
that at least three (3) years have passed after I successfully completed a sentence for a Class A, B or C/ Levels 1-5 Felony offense.

Name

First

Last

Please list any previous names

knowledge. Date best

Date of birth

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address - within the last 5 years, please list.

Race (choose all that apply)

Options taken from Federal Data options

Gender

Female
Male

The information contained on this form is correct to the best of my knowledge. I agree to all terms.

I agree. I give my consent for LCS to initiate a criminal background check with the Indiana State Police. I affirm, under the penalty for perjury, that the foregoing information is accurate.

Signature

Clear Signature

Today's date