Instructions to Complete a Background Check and the Safe Environment Program

Transcription

1 Instructions to Complete a Background Check and the Safe Environment Program If you are a Homeroom Mom or are planning on attending a field trip as a chaperone, you must complete these two requirements. 1. Complete the MA Homeroom Moms/Volunteer Participation Form and Authorization, Consent and Release for Background Check. Please do not forget to sign it! Return the signed form to Olga Bailin in the Business Office, or drop off at the AHN Front Desk and ask to have it directed to Olga. Please note: This form is good for five years; if you ve completed it in the past and are unsure whether you are still current, Olga Bailin to find out if an updated form is needed. 2. Complete the online a Safe Environment Program through the Diocese of St. Petersburg. Instructions to do so are included below. Once completed you must bring your Certificates of Completion* to Olga Bailin in the Business Office, or drop off at the AHN Front Desk and ask to have it directed to Olga. * 1. Recognize and Report Child Abuse 2. Detecting Predators Please Note: If you completed a Safe Environment Training Course in the past but the school does not have a record of it, or you do not have your certificate, you can contact the Diocese s Safe Environment Training Program at (727) , ext and ask for Michael Craig. Michael should be able to get you a copy of your certificate. Important: If you ve previously taken a Safe Environment Training Course but it s been five years, it s time to renew. Please follow the instructions to complete the Safe Environment Program. Please Note: If you are unsure of when you attended your Safe Environment Training Course, you can Olga Bailin to find out the date that you attended.

2 ACADEMY OF THE HOLY NAMES MOTHER S ASSOCIATION HOMEROOM MOMS - VOLUNTEER PARTICIPATION FORM Dear Volunteer: Thank you for offering your time and talent to work with our students and others in our school. A volunteer, such as yourself, is indispensable to our ministry and programs here at the Academy of the Holy Names. The policy of the Academy of the Holy Names requires background screening for all employees of the hiring entity. Because you will be volunteering and working with our young people, we also require some basic information about you, which assures the best possible program and safety for all. Please print your responses to the following questions and return this form to the School Administrator or school office. Name: S S #: Date of Birth Address: City State Zip Driver s License #: State: Race: Sex: Volunteer position(s) you are seeking: Prior experience working with youth: Have you ever been arrested:? Yes No If yes, what was the result of the arrest? (Include adjudication withheld and plea of nolo contendere) Have you ever been the subject of an investigation involving an allegation of sexual abuse? Yes No If yes please explain: Have you ever been a defendant in a civil action for an intentional tort? (e.g. assault, battery, etc.) Yes No If yes, please explain, including nature of the intentional tort and date it was committed: Has your employment ever been terminated for reasons related to allegations of physical/verbal abuse or sexual harassment? Yes No If yes, please explain:

3 Authorization: In conjunction with my request to serve as a volunteer for the above position, I understand that investigative inquires on my background are to be made on me, to assess whether any reason exists that would suggest that I not be accepted for the position. These inquiries will be made according to policies of the hiring entity and will consist of a criminal background check using the services of Premier InfoSource. The information received will be kept confidential and will be used only to determine my suitability to volunteer for the above noted position. I authorize without reservation, any party contacted to furnish any or all of the above-mentioned information. Further, I will allow a photocopy of this authorization to be as valid as the original for purposes conducting the necessary investigation. In addition, I agree to abide by the policies, procedures and code of conduct that currently exist or may be amended in the future by the entity for which I am volunteering. Signature of Volunteer Date *NOTE: Date of birth, sex, and race are being requested only for purposes of identification in obtaining accurate retrieval of records.

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