OREGON DEPARTMENT OF EDUCATION

[Pages:1]Phoenix-Talent School District #4 401 W. Fourth Street-P.O. Box 698 Phoenix, OR 97535

PHS PES

TMS

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VOLUNTEER CRIMINAL HISTORY VERIFICATION

Student and staff safety is a priority for Phoenix-Talent Schools. Your application cannot be processed unless all the requested information is provided and you authorize Phoenix-Talent Schools to conduct a criminal background check. Type or print clearly.

Full Name ______________________________________________________________________________________

Last

First

Full Middle

Other Names Used ___________________________________ Date of Birth ______________________________

Address ________________________________________________________________________________________

Phone No. __________________________

Email Address ________________________________________

Driver's License No. ___________________

Social Security Number _______________________________

Are you a parent, guardian or have other familial relation to a student?

Yes

No

Student(s) name(s) _______________________________________________________________________________

Have your services been requested by a staff member?

Yes

No

Staff Member/Program/Position ____________________________________________________________________

If you answer "yes" to any question please attach an explanation stating the date and nature of the conviction/arrest.

A. Have you previously completed a "volunteer criminal history verification" form for the Phoenix-Talent Schools?

Yes

No

If yes, when? ____ _________________________________

B. How long have you resided in Oregon? _____ If less than 3 years, identify previous state of residence. ________

C. Have you ever been convicted of a sex-related crime?

Yes

No

If yes, was the conviction in Oregon or in another state? (Please specify if in another state.) __________________

If yes, did the crime involve force or minors?

Yes

No

D. Have you ever been convicted of a crime involving violence or the threat of violence?

Yes No

If yes, was the conviction in Oregon or in another state? (Please specify if in another state.) ___________________

E. Have you ever been convicted of a crime involving drugs or alcoholic beverages?

Yes

No

If yes, was the conviction in Oregon or in another state? (Please specify if in another state.) __________________

F. Have you ever been convicted of any other crime except a minor traffic violation?

Yes No

G. Have you been arrested for a crime for which there has not yet been an acquittal or dismissal?

Yes

No

I hereby grant to the Phoenix-Talent School District permission to check civil or criminal records to verify any statement made on this form.

__________________________________________ _____________________________________

Applicant's Signature

Date

The Phoenix-Talent School District will conduct a criminal offender record check of volunteers and student interns working with or around children. The applicant is entitled to review his/her criminal history for inaccurate or incomplete information. Discrimination on the basis of arrest records alone may violate federal civil rights law. The applicant may obtain further Information concerning the applicant's rights by contacting the Bureau of Labor and Industries, Civil Rights Division, State Office Building, Suite 1070, Portland, Oregon 97232.

Form A-220 (11/14)

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