NORTHVIEW PUBLIC SCHOOLS
NORTHVIEW PUBLIC SCHOOLS
4365 Hunsberger N.E., Grand Rapids, MI 49525
Phone: 616-363-6861 -- Fax: 616-363-9609
THIS FORM WILL BE KEPT CONFIDENTIAL
The Northview Public Schools, parents and volunteers have worked hard together to create a partnership. In a continued effort to keep our schools as safe as possible, we are asking volunteer parents and community members to submit to criminal background checks. Our volunteers generously give their time to Northview students in many ways. As we do with all adults who supervise our students, if you choose to participate as a volunteer, we ask that you complete this form. If you do not wish to complete the form, then volunteer activities will be limited to group situations as approved by the principal or superintendent. The Volunteer Consent Form and any response will be kept confidential with the Principal of the school building and Superintendent (or designee). Thank you for your understanding with this matter and for all that you give to our schools, community and children. You need only submit this form once per school year.
Dr. Michael Paskewicz
Superintendent
VOLUNTEER CONSENT FORM
ONE FORM PER PERSON COVERS ALL STUDENTS AND ONE NAME PER FORM
(Check one box, please)
? Parent/Guardian ? Grandparent ? Other_____________________
PLEASE PRINT:
Last Name:_____________________First Name:___________________Middle Initial:_______
Race:_____________________ Sex:_______
Date of Birth:________________________________
Per District Policy 9120: Any photographs taken at any activity, school or non-school related, must be submitted to the principal for approval prior to use to avoid possible invasion of privacy situations. ______________________
Initial (s)
LIST ALL BUILDINGS YOU WILL BE VOLUNTEERING IN:________________________________
__________________________________________________________________________________
I understand the Central Records Division of the Michigan State Police, Lansing, Michigan, requires the
above information. I authorize Northview Public Schools to utilize the above information for the sole
purpose of obtaining a conviction-only criminal history file search.
VOLUNTEER’S SIGNATURE: DATE:_________________
VOLUNTEER’S PRINTED NAME _________________________STUDENT NAME____________________
ADDRESS_______________________________________________ PHONE_______________
*************************************(Office Use Only)*************************************
DATE RECEIVED: DATE SCREENED:
VOLUNTEER STATUS:
θ OK
θ DENIED
IF DENIED, DATE REPORTED TO BUILDING/PROGRAM SUPERVISOR:
REVISED 10-12-12
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