Volunteer Background Check

Acknowledgement Form for "Non-employment Background Checks Only"

Service to Provide: *
Date to Provide Service: *
In order to ensure the protection of children in the care of Zion Lutheran School, school policy requires prior to any and all persons providing a volunteer service at the school or for any function conducted b the school; all potential volunteers complete a State of Michigan background check. The background check is a name check only, through the State of Michigan ICHAT system and is based on individual identifiers. Any application declining to complete a "Volunteer Background Check" acknowledgement form will not be considered.
Potential Volunteer Information
Full Name: Full Name: * First Middle Last
Maiden name or other names(s) previously used: *
Date of Birth Date of Birth * / MM / DD YYYY
Sex:

Sex: Male Female
Eye Color: *
Hair Color: *
Height: *
History Information

Complete the information below.
1. Have you ever volunteered at Zion before? *

1. Have you ever volunteered at Zion before? Yes No
2. Have you ever plead guilty or been convicted of a felony in a state or federal court? *

2. Have you ever plead guilty or been convicted of a felony in a state or federal court? Yes No
If yes, Provide the Data and Sate offense/conviction occurred:
If yes, provide a detail description of the conviction:
3. Have you ever plead guilty or been convicted of a misdemeanor in a state or federal court? *

3. Have you ever plead guilty or been convicted of a misdemeanor in a state or federal court? Yes No
If yes, Provide the Data and Sate offense/conviction occurred:
If yes, provide a detail description of the conviction:
4. Are you the subject of a current criminal investigation or have pending charges against you? *

4. Are you the subject of a current criminal investigation or have pending charges against you? Yes No
If Yes, Date and State the investigation is ongoing:
If yes, provide a detailed description of the investigation or pending charges:
Provide the Last 4 Numbers of your Social Security Number:
Zion Lutheran School reserves the right to "approve" or "deny" any volunteer service upon review of the background check returned through ICHAT. The determination will be based upon the individual's fitness to have responsibility for the safety and well being of children. Providing false information, or information contradicting the background check information, is grounds for immediate volunteer denial.

By affixing our signature to this form you acknowledge your statements are to be true and give full consent to complete a name based on based background through ICHAT.
Draw your signature into the box below. *

Clear
Date of Signature Date of Signature * / MM / DD YYYY
OFFICE USE ONLY:

OFFICE USE ONLY: Approved Denied Date Approved/Denied Date Approved/Denied
Determining Staff Member:
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In the number 91723, what is the 2nd digit?

Volunteer Background Check

Volunteer Background Check

Potential Volunteer Information

History Information