SNYDER INDEPENDENT SCHOOL DISTRICT Criminal History Record Information Request - Volunteers CONFIDENTIAL The Snyder Independent School District is allowed by state law to obtain criminal history record information on individuals who intend to serve as volunteers with the district (Texas Education Code Section § 22.083). The information requested below is necessary to obtain criminal history record information. All information will be kept confidential and only accessible to authorized district employees.

Please Print and Complete ALL Fields

_______________________________________________________________________ Last Name

First Name

Middle Name or Initial

_____________________________________________________________________________________ Maiden or other name(s) used in any and all other records of birth or records of residence. _____________________________________________________________________________________ Address _____________________________________________________________________________________ City County State Zip ________________________________________________________________________ Date of Birth Social Security Number Gender _____________________________________________________________________________________ Driver’s License Number Issuing State DL Exp. Date Phone Number

Ethnicity:  White (not of Hispanic origin)  Black (not of Hispanic origin)  Hispanic Asian or Pacific Islander  American Indian or Alaskan Native A Copy of a Driver License or State Issued Identification Card is Required and MUST accompany this form I understand the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for volunteering, but will be used solely for the purpose of obtaining criminal history record information.

______________________________________ Signature

______________________________________ Date

OFFICE USE ONLY: Campus Making Request

SHS

_________________________________________________________ Phone number (Home) _________________________________________________________ Phone number (cell)

SJHS

SIS

SPS

Reviewed by HR:______________ Approved

Denied

This form will be filed in the Personnel Office at the school administration building.

This school district and its Career and Technology Education Program does not discriminate on the basis of sex, disability, race, color, age or national origin in its educational programs, activities, or employment as required by Title IX, Section 504 and Title VI.

Este distrito escolar y su Programa Educacional de Carerra y Technologia no discriminan en base a sexo, disabilidad, raza, color, edad u origen nacional en sus programas educativos, actividades, o empleo como lo requiere el Titulo IX, Seccion 504 y Titulo VI

1. Have you ever been convicted or pled guilty before a court for any federal, state or municipal criminal offense?  (Exclude minor traffic misdemeanors). YES  NO If yes, please provide details below: State _______________________ County ___________________ Date of Offense _________________ Details of conviction: _____________________________________________________________________________________ _____________________________________________________________________________________ 2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offense?  YES NO If yes, please provide details below: State _____________________ County ___________________ Date of Offense ___________________ Details of offense: _____________________________________________________________________________________ _____________________________________________________________________________________ 3. Have you ever received probation or community supervision for any federal, state or municipal offense? YES NO If yes, please provide details below: State ______________________ County __________________ Date of Offense ___________________ Details of supervision: _____________________________________________________________________________________ _____________________________________________________________________________________ 4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?  YES NO If yes, provide details below. Country ________________________ City _____________________ Date of Offense ______________ Details of conviction: _____________________________________________________________________________________ _____________________________________________________________________________________ 5. As of the date of this consent form, do you have any pending charges against you?  YES NO If yes, please provide details below. State ________________________ County ____________________ Date of Arrest ________________ Details of pending charges: _____________________________________________________________________________________ _____________________________________________________________________________________ I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS CONSENT FORM IS TRUE, CORRECT AND COMPLETE. IF ANY INFORMATION PROVES TO BE INCORRECT OR INCOMPLETE, I UNDERSTAND IT MAY BE USED AT THE DISCRETION OF THE DISTRICT INCLUDING DENIAL OF VOLUNTEERISM DUTIES. DATE________________________ APPLICANT’S SIGNATURE ___________________________________________________________ APPLICANT (PRINT NAME)