ISHPEMING PUBLIC SCHOOL DISTRICT NO. 1 Rev. [7/13] Service to provide: VOLUNTEER BACKGROUND CHECK Acknowledgment Form *Non-employment Background Checks Only* Date to Provide Service: In order to ensure the protection of children in the care of Ishpeming Public School District No. 1, school policy requires, prior to any and all persons providing a volunteer service at the school or for any function conducted by 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 applicant declining to complete a Volunteer Background Check acknowledgment form will not be considered. POTENTIAL VOLUNTEER INFORMATION Full Printed Name: Maiden name or other name(s) previously used: DOB: Sex: Eye Color: Hair Color: Height: [mm/dd/yyyy] HISTORY INFORMATION 1) Have you volunteered at Ishpeming Public School District No. 1 before? Yes No 2) Have you ever pled guilty, or been convicted of a felony in a state or federal c court? Yes No Date and state offense/conviction occurred: If yes, provide a detailed description of the conviction: 3) Have you ever pled guilty, or been convicted of a misdemeanor in a state or federal court? Yes No Date and state offense/misdemeanor occurred: If yes, provide a detailed description of the conviction: 4) Are you the subject of a current criminal investigation or have pending charges against you? Yes No Page 1 of 2
ISHPEMING PUBLIC SCHOOL DISTRICT NO. 1 Rev. [7/13] Date and state the investigation is ongoing: If yes, provide a detailed descripition of the investigation or pending charges: Ishpeming Public School District No. 1 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 wellbeing of children. Providing false information, or information contradicting the background check information, is grounds for immediate volunteer denial. By affixing your signature to this form you acknowledge your statements are to be true and give full consent to complete a name based background check through ICHAT. Signature: Date Signed: Please return completed form to Ishpeming Public School District No. 1 ~ 319 East Division Street, Ishpeming, MI 49849. Questions or concerns, please contact Connie Bertucci @ 906.485.5501 Ext. 131. OFFICE USE ONLY Approved Denied Date Approved/Denied [mm/dd/yy] Determining Staff Member [Initials] Page 2 of 2
3120.09 F1/page 1 of 1 VOLUNTEER RELEASE FORM I have offered my services as a volunteer to help the School District in the following areas: I agree to abide by all relevant Board policies and administrative guidelines while on duty for the District. I understand that, although I am covered under the District's liability insurance policy, I am not covered by its health insurance policy nor am I eligible for workers' compensation. Should I become ill or suffer an accident while doing volunteer work for the District, I agree that I shall be responsible for any and all hospital and medical charges that may accrue. I understand further that, as a volunteer, I am not in any manner considered an employee of the District or entitled to any benefits provided to employees. I further release the Board of Education from any and all liability for any damages, whatever their nature, which may result as a consequence of my volunteer services. For the protection of the children in the school, the District is required by law to inquire of its staff members whether or not they have ever been convicted of a crime related to children. We would appreciate your cooperation by indicating that you have never been convicted of any of the following offenses: aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, aggravated menacing, abuse or neglect of a child, kidnapping, abduction, child stealing, criminal child enticement, rape, sexual battery, corruption of a minor, gross sexual imposition, importuning, voyeurism, public indecency, felonious sexual penetration, compelling prostitution, promoting prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity, pandering obscenity involving a minor, pandering sexually-oriented matter involving a minor, illegal use of a minor in nudity-oriented material or performance, endangering children, contributing to the delinquency of children, carrying concealed weapons, improperly discharging a firearm at or into a school or house, corrupting another with drugs, placing harmful objects in or adulterating food or confection Volunteer District Witness Date NEOLA 2009
Ishpeming Public School District No. 1 319 East Division Street Ishpeming, Michigan 49849 Background check ~ IChat As a volunteer working with K-12 students in the State of Michigan you are required to have an IChat background check completed. Please complete the following: Last Name: First Name: Middle Initial: Race: White Sex: Male Female Black Asian or Pacific Islander American Indian or Alaskan Native Unkown Year of Birth: Month of Birth: Date of Birth: Other Last Name: Other First Name: Other Middle Initial: Other Last Name: Other First Name: Other Middle Initial: Position: Please provide a copy of a valid Driver s License when submitting this form to: Office of the Superintendent 319 East Division Street Ishpeming, MI 49849 Signature Date Another Century of Excellence
ISHPEMING PUBLIC SCHOOL DISTRICT NO. 1 319 E. Division Street Ishpeming, MI 49849 (906) 485-5501 Application for Employment NON-Certified / Licensed Position GENERAL Date: Name: Address: E-Mail: Last First Middle Street City State Zip Telephone: Are you legally entitled to work in the United States? Yes No JOB INTEREST State clearly the position for which application is being made: Full Time Part Time Temporary Would you: Work Nights? Weekends? Holidays? What salary range would you consider appropriate? How did you learn of this vacancy? If you are currently employed, may we contact your current employer? Yes No May we contact you at your business phone? Yes No Number to call: Date available for work? EDUCATION Type of School Name and Location of School Graduated Degree Courses Specialized In High School Yes / No (Circle One) College Year Trade School Year Other Year LICENSING AND CERTIFICATION List any applicable license or certificates. Proof of licensing or certification may be required by the District.
DRIVER / CDL If applying for a position that requires driving, do you have a valid driver's license? Yes No CDL? Yes No State: License Number: SKILLS AND ABILITIES List any professional, trade, office, technical, or other skills and abilities possessed by you (i.e., typing, shorthand, office machines, keypunch, electrical, mechanical, custodial, cooking, etc.) Skills Length and Kind of Training Years of Experience List other relevant experiences (such as working with youth of school age, etc.) PERSONAL HISTORY Are there any pending felony charges against you? Yes No Have you ever been convicted of a crime? Yes No (Pending felony charges or conviction of a crime will not necessarily prohibit employment but may be considered in relation to certain job requirements. Fingerprinting, and criminal history checks, may be required by the District.) Have you missed more than five scheduled work days in any one of the last five years? Yes No Have you ever been disciplined or discharged for absenteeism, tardiness, failure to notify your company when absent or any other attendance related reasons? Yes No Have you ever been disciplined or discharged for theft, unauthorized removal of company property or related offenses? Yes No Have you ever been disciplined or discharged for being under the influence of alcohol or drugs or possession, use or abuse of alcohol or drugs? Yes No Have you ever been disciplined or discharged for insubordination? Yes No Have you ever been disciplined or discharged for violating a safety rule(s)? Yes No If you answered yes to any of the proceeding questions, please explain:
MILITARY RECORD Have you served in any United States military service? Yes No If yes, indicate period: From To Branch Type of Discharge Special training received Rank or Rating EMPLOYMENT HISTORY List previous employers -- Most recent first Include all positions with each employer. Use remarks section on next page or add additional space if more space is required. Attach resume if available. Dates Month Year Employer Responsibilities From Name Title of Position To Address (include city & state) Duties (including supervision) Type of business Supervisor's Name Final Salary Reason for Leaving From Name Title of Position To Address (include city & state) Duties (including supervision) Type of business Supervisor's Name Final Salary Reason for Leaving From Name Title of Position To Address (include city & state) Duties (including supervision) Type of business Supervisor's Name Final Salary Reason for Leaving
REFERENCES Include individual's name, address, telephone number, occupation and years known. Do not use relatives. REMARKS Other remarks that will support your candidacy: POLICY STATEMENTS DRUG - FREE WORKPLACE ACT The Ishpeming School District, in compliance with the Drug - Free Workplace Act of 1988, as amended, certifies that we will maintain a drug-free workplace by prohibiting the unlawful manufacture, distribution, dispensing, possession or use of any controlled substance by any employee in the workplace and will enforce strict sanctions, up to and including discharge, for any violation of this policy. IMMIGRATION REFORM AND CONTROL ACT The Ishpeming School District is required by law to verify all new employees' eligibility for employment in the United States. A new employee must provide the school with documentation of his/her authorization to work and proper identification within the first three days of employment. Employment will be terminated if appropriate documentation is not submitted. A list of acceptable documents is available in the Personnel Office, 319 E. Division Street, Ishpeming, Michigan 49849. AA/EEO STATEMENT The filing of this application does not imply that the applicant will eventually be employed. The applicant will be considered when a vacancy for which he or she is qualified occurs in competition with other applicants. All applicants will be given equal opportunity without unlawful regard for race, color, religion, national origin, sex, age, marital, dependent, or veteran status, physical or mental disability, height, weight or any other legally protected status. The Ishpeming School District is an Affirmative Action/Equal Opportunity Employer.
ACKNOWLEDGEMENT AND CERTIFICATION I acknowledge that consideration for employment is contingent upon the results of a reference and background check and, if I am offered employment, that my employment is conditional until the results of any required criminal records checks and/or post-offer physicals are known. I hereby consent to required fingerprinting and criminal records checks and, should I be offered employment, to required post-offer physicals, including drug screening. I authorize you to investigate the truthfulness of all statements in this application or in connection with any post-offer physicals, to contact former employers and other listed references or any other persons who can verify information and to discuss the results of any investigation with the employees of the District involved in the hiring process. I give my consent for all contacted persons to provide any information concerning this application, including any post-offer physicals, and authorize release of information concerning disciplinary action without any obligation to give me written notice of such disclosure. I agree to execute any lawful releases, consents and waivers required by you. I hereby release you and any other person from any liability whatsoever as a result of such inquiries and disclosures. I understand that if I have a disability, and need accommodation in any step of the hiring process, or to assist me in any demonstration (required of all applicants for the job) of qualifications to perform the duties of the job for which I am applying, I should inform the personnel office. Failure to notify the District may preclude any claim that the District failed to reasonably accommodate my disability. Any misrepresentation in this application or other information submitted by me, any refusal by me to sign lawfully required releases, consents or waivers, and any failure by me to properly complete any lawfully required forms (I-9, W-4, etc.) may result in cancellation of this application for employment and/or separation from the District's employ, if I have been employed. I certify that I have read and understand the above stated policies and that I will, if I accept employment with the Ishpeming School District, comply with these and all other school policies, rules, and regulations. Unless otherwise provided in writing, my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the District or myself. I understand that no representative of the District, except by specific written authority of the President of the Ishpeming School District Board, has authority to enter into any agreement of any specified time or to make any agreement contrary to the foregoing. I CERTIFY THAT I HAVE READ THIS ENTIRE APPLICATION AND ALL OTHER INFORMATION PROVIDED BY ME AND THAT ALL INFORMATION IS TRUE AND CORRECT. Signature of Applicant Date INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED. This application will be kept on active file for one year. The Ishpeming Public School District Board of Education does not discriminate on the basis of race, color, religion, national origin, sex, disability, age, height, weight, marital status, genetic information, or any other legally protected characteristic, in its programs and activities, including employment opportunities.