AUTHORIZATION AND REQUEST FOR
CRIMINAL RECORDS CHECK
 
A criminal records check is required for anyone working with children in Preschool and Elementary grades.  To authorize a criminal records check, please complete the form below.  Since a signature is required and the form includes a Social Security number, please print the completed form and give it to Herb Case.
 
 
 

Full Legal Name (First, Middle, Last)

Former Name(s) (Maiden name, etc.)

Social Security Number

Date of Birth

Gender
MaleFemale

Ethnicity/Race

Phone Number

Driver's License Number

Driver's License State

Email

Current Street Address

Current City, State, ZIP

Current Address Since