Treetops School International

Treetops School International: Criminal History Check Authorization, Texas Department of Public Safety

This application is being used to provide a safe and secure environment for Treetops School students. The requested information regarding sex, race, and the date of birth is required bye Texas Department of public Safety. This information o slept strictly confidential and is necessary only for the processing of the criminal background check. This information will only be released as required by law.

Full Name: _________________________________________ Former Name:__________________

Alias:____________________________________ Maiden Name:________________________

Gender: M ______ or F ________

Race: American Indian Asian Black Hispanic White Other

Date of Birth: _______________ Place of Birth: ________________________

Social Security Number: ___________________________________________

Drivers License #: ___________________________ State: _______________

Have you ever been convicted or received deferred adjudication for a crime other than a minor traffic offense? ________ Yes or __________ No

An individual with a history of any child abuse related or child molestation related offense occurring at any time during his history will not be placed on the list of approved volunteers. If the Texas Department of Public Safety returns apparent criminal history for anything other than minor offenses during the past 15 years, you will not be placed on the school list of approved volunteers. You may contest your status by providing official proof that the record is clear or by submitting a written appeal to the Board of Directors.

IN ORDER TO PROTECT THE STUDENTS OF TREETOPS SCHOOL, WE ASK OUR VOLUNTEERS TO READ AND SIGN THE FOLLOWING:

I, the undersigned, authorize Treetops School to request and receive copies of any information pertaining to any criminal history recorded maintained by any law enforcement agency, and to use said information for the purpose of evaluating my application for volunteering. I hereby authorize treetops to request any relevant information from my employer 9s) and I authorize any references to release such information. I affirm that all the information contained in this application is true and complete and that misrepresentation falsification or omission shall be cause for relinquishing my role as a volunteer with Treetops.

_____________________________________ ______________________________
Signature Date
_____________________________________ _______________________________
Home Address Home Phone

For office use only:
Date submitted:______________________ Results Received:_________

Treetops School International: Approved Volunteer List