Full name of potential volunteer
Help for Full name of potential volunteer
Please enter your full first and last names.
School I wish to volunteer with
PW Elementary School
Name of student you are associated with at the school.
Classroom/teacher you would be volunteering with/for
Help for Classroom/teacher you would be volunteering with/for
Please name the classroom grade (if elementary) and/or teacher's name you are planning to help by volunteering.
Help for Teacher's Classroom/Event
Please add the teacher's name and the name of the event that you are volunteering for.
I represent that (please check ONLY ONE of the two boxes below.)
I have not been convicted of, nor pled guilty or nolo contendre (no contest) TO ANY CRIMES. (If you are in doubt, please check the next box and explain.)
I have been convicted of, or pled guilty or nolo contendre (no contest) to the following crimes. (Please use next section to explain the nature of conviction, date, and court.)
Conviction history information
Help for Conviction history information
Nature of conviction, date, and court)
I understand and agree that Pewamo-Westphalia Community Schools will conduct a criminal record check through the Michigan State Police.
If the report received from the State Police is not the same as my representation(s) above respecting either the absence of ANY conviction(s) or any crimes of which I have been convicted, I will not be allowed to volunteer in the capacity of a volunteer/chaperone for Pewamo-Westphalia Community Schools.
I may not be allowed to volunteer in any capacity, depending upon the findings of this criminal check.
Help for Legal name
Please enter in this order: last, first, middle initial
Any other names used (including maiden name):
Date of birth
American Indian or Alaskan Native
Asian or Pacific Islander
I understand that the above information is required by the Central Records Division of the Michigan State Police. I authorize the Pewamo-Westphalia Community School District to utilize the above information for the sole purpose of obtaining a background check via the Internet Criminal History Access Tool (ICHAT) with the Michigan State Police and sex offender's registry file search.
Help for Signature
Typing your name here indicates your agreement to the submission of this form to the Michigan State Police for the background check.