ANN ARBOR PUBLIC SCHOOLS ADMINISTRATIVE AND HUMAN RESOURCE SERVICES VOLUNTEER CERTIFICATION FORM Michigan Makers at

Dear Volunteer, Scarlett and/or Mitchell Your contribution of your valuable time is a special gift. You Thank you for agreeing to volunteer at ________________________________. are contributing SS to the Board of Education’s top goal of student achievement. The safety of students, staff, volunteers, and guests in our buildings is a top priority of AAPS. The Board has developed policies to help ensure the safety of all who interact with students and staff. All AAPS employees and unsupervised volunteers are required by Board Policy, 7350 to undergo a criminal background check. The AAPS uses the I-Chat (Michigan State Police) system to perform background checks. All information gathered through the background check is confidential.

Please complete the following: Name__________________________________________

Maiden Name ___________________________________

Date of Birth ____________________________________

Alias___________________________________________

Gender

State ___________________________________

M

F

Ethnic: African American____ American Indian____ Asian____ Hispanic____ White____ Middle Eastern____ Other____

Pursuant to Public Act 68 of 1993, I represent that (check one): 1.

I have never been convicted of or pled guilty or nolo contendere (no contest) to any crimes.

2.

I have been convicted of or pled guilty or nolo contendere (no contest) to the following crimes: (Use other side of this form, if necessary, to explain nature of conviction, date and court.) A. ____________________________________________________________________________________ ____________________________________________________________________________________ B. ____________________________________________________________________________________ ____________________________________________________________________________________ C. ____________________________________________________________________________________ ____________________________________________________________________________________ D. ____________________________________________________________________________________ ____________________________________________________________________________________

Pursuant to Public Act 68 of 1993, I understand and agree that: •

The Board of Education of the school district or governing body of the non-public school (the “School” must request a criminal history check on me from the Central Records Division of the Michigan Department of State Police.



Until that report is received and reviewed by the School, I am not able to volunteer; and



If the report received from the Department of State Police is not the same as my representation(s) above, respecting either the absence of any violation(s) or any crimes of which I have been convicted, I shall not be permitted to volunteer for Ann Arbor Public Schools.

Signed:________________________________________

7, 2014 Date: October _______________________________

THE INFORMATION PROVIDED ON THIS DOCUMENT WILL REMAIN CONFIDENTIAL AND BE HELD AT THE AAPS HRS OFFICES 2555 S. STATE, ANN ARBOR, MI 48104 Shonta Green 7/30/08

criminal background check form for Scarlett and Mitchell - blank.pdf ...

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