Street Address

City, State, and Zip Code

Telephone Number

Date:___________________

The following named individual has made application with this School District for employment or provision of athletic coaching services or other extracurricular academic coaching services.

Full Name of Individual:__________________________________________________________

(please print) Last First Middle

Maiden, Previous, Alias:__________________________________________________________

Date of Birth:_________________________ Sex (M or F): ________

Month/Day/Year

I authorize the Minnesota Bureau of Criminal Apprehension to disclose all criminal history record information to ____________________________________________________________

pursuant to Minn. Stat. § 123B.03 for the purpose of ___________________________________

_________________________________________ with this School District.

CONDITIONAL HIRING: I understand that the School District may permit me to commence my employment duties or provide athletic coaching services or other extracurricular academic coaching services pending completion of the criminal history background check and acknowledge and agree that my employment or services may be terminated based on the result of the background check.

The expiration of this authorization shall be for a period no longer than one year from the date of my signature.

__________________________________________ __________________

Signature of Applicant or Potential Service Provider Date

Subscribed and sworn to before me

this _____ day of __________, 20___.

_________________________________

Notary Public

EMPLOYMENT AND SERVICES CRIMINAL HISTORY BACKGROUND CHECKS

NOTICE TO PARENTS AND GUARDIANS

The school district has adopted a policy, the purpose of which is to promote the physical, social, and psychological well-being of its students. Pursuant to this policy, the school district shall seek criminal history background checks for all applicants who receive an offer of employment with the school district. The school district also shall seek criminal history background checks for all individuals, except enrolled student volunteers, who are offered the opportunity to provide athletic coaching services or other extracurricular academic coaching services to the school district, regardless of whether compensation is paid. These positions include, but are not limited to, all athletic coaches, extracurricular academic coaches, assistants, and advisors. The school district may elect to seek criminal history background checks for other volunteers, independent contractors, and student employees.