I-Chat Authorization for Background Check

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

In order to ensure the protection of children in the care of Goodrich Area Schools, district policy requires all adult volunteers and visitors to complete a State of Michigan I-CHAT background check prior to attending any events at the school or for any function conducted by the school. I-CHAT is a name check only, through the State of Michigan . Any applicant declining to complete a “Volunteer Background Check” acknowledgment form will not be permitted access past the building office throughout the district. This form gives us your permission to perform a background check. The I-Chat form will need to be filled out after July 1 each school year, by each individual and applies district-wide for all children in the family.

Thank you for your understanding of our policy. Please contact your child's Building Administrator if you have questions or concerns.

Name, (Last, First, Middle) *

Date of Birth *

Sex *

Female

Male

Race *

Asian or Pacific Islander

American Indiant

Hispanic

African American

White (Non-Hispanic)

Other:

Additional Names (including Maiden Name)

Home Address (street, City, State, Zip) *

Phone Number *

Please list all child(ren) attending Goodrich Area Schools including the Children's Center and GSRP programs

Please check building(s) you plan to visit *

Reid

Oaktree

Middle School

High School

Children's Center/GSRP

Other:

Required

What is the purpose of your visit? *

Classroom Help/Student Support including WatchDog program

Classroom Visits, Party, Special Events

Field Trip

Coaching

Other (please list)

Required

Pursuant to 1993 Public Act 68, I represent that (please check one) *

No, I have not been convicted of, or pled guilty or nolo contendere (no contest) to any crimes.

Yes, I have been convicted of or pled guilty or nolo contendere (no contest) to a crime(s). Please list in the following question.

If you answered YES above, please list crime(s) below. Explain nature of conviction, date and court.

I understand that it is my responsibility as a volunteer to protect the privacy of all students and staff members that I may encounter within my volunteer experience by refusing to share personally identifiable information with others in the community. I acknowledge that such sharing could result in revocation of my privilege to volunteer. *

Yes, I agree and acknowledge my responsibility to protect the privacy of all students and staff.

Required

I understand the personal information on this form is used to conduct a search for prior criminal records. By checking "YES" below, I hereby authorize Goodrich Area Schools to conduct this search. *

Yes, I authorize Goodrich Area Schools to conduct a search for any prior criminal records.

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Goodrich Area Schools. Report Abuse

Forms