This application is for all individuals under the age of 18. Please answer all questions on this form. Incomplete information may cause your application to 
be delayed, rejected, or returned. Please print legibly and clearly. **Only Student Workers, those who are in a paid position with the Salem-Keizer 
School District, will need to disclose their social security number. 

 
Student Volunteers and Student Workers
Criminal History Check Statement
State 

Drivers License/ 
Permit/ID Number 
(Optional) 

Last Name 

Legal First Name 

Full Middle Name

Date of 
Birth 
mm/dd/yr 

Sex 

Social Security Number 
(Required for Student 
Workers only)** 

 

 

 

 

 

 

 

 

 



 

Address _________________________________________________________ City _____________ State ___________ Zip ____________ 

 

Home Telephone ( ) _________________________ Cell Phone ( ) _____________________ Message Phone ( ) _______________ 

 

A. List other names previously used ______________________________________________________________________________________ 

 

B. List other states where you have resided _________________________________________________________________________________ 

 

YOU MUST CHECK YES OR NO. FALSIFYING OR NOT DISCLOSING INFORMATION WILL RESULT IN DISQUALIFICATION 
OF APPLICATION OR TERMINATION OF VOLUNTEER ASSIGNMENT OR EMPLOYMENT. 

 

Have you ever been convicted in adult court; referred to or placed in the jurisdiction of any juvenile court or juvenile department; or 
convicted of or admitted to any crime or law violation involving any of the following? If yes, to any of the questions below, please explain 
on a separate sheet of paper and attach. 

 

1. Sex-related crime? __________________________________________List state and county______________________ Yes No 

 

2. Crime or violation involving violence or threat of violence? _________ List state and county______________________ Yes No 

 

3. Restraining order or stalking order? _____________________________List state and county______________________ Yes No 

 

4. Criminal activity involving drugs? ______________________________List state and county______________________ Yes No 

 

5. Criminal activity involving alcohol? ____________________________List state and county_______________________ Yes No 

 

6. Crime or violation involving theft? _____________________________List state and county_______________________ Yes No 

 

7. Any other crime or violation except a minor traffic violation? ________List state and county_______________________ Yes No 

 

8. A crime or violation that is in the court but not yet resolved? _________List state and county_______________________ Yes No 

 

School currently attending ______________________________________________ Volunteer Location: _______________________________ 

 

AUTHORIZATION TO RELEASE INFORMATION 

(RELEASE FROM LIABILITY AND WAIVER) 

 

To any law enforcement agencies, civil records authorities, and Salem-Keizer Public School District: I authorize you to release to the Salem-
Keizer School District any and all information and civil or criminal records naming me, including all entries where I am named as being arrested, 
as a suspect, as being cited for any crime, violation, infraction or offense, or as otherwise involved or named in any report by any member agency 
of your organization. 

 

I, personally and on behalf of any subsequent representative of my estate, hereby forever release you, your organization, it’s member agencies, 
member agency parent governments, and all their officers and employees, from any liability or damage, either direct or indirect, which may result 
from furnishing the information requested and will hold harmless the law enforcement agencies, and the Salem-Keizer School District from the 
provision or use of any information so obtained regardless of whether it should be later proven to be factual or not factual. This form may not be 
altered. 

____________________________________________________ ___________________________________________________________ 

Student Signature Date Parent/Guardian Signature Date 

 (Required) 

 

Office Use Only: 

 Job Title _______________________ Location/Supervisor _______________________ Ext#_______ Hire Date ___________ 

 



 

 

 

Checklist 

Student Criminal History Check Statement 

 

 

 

Please review the checklist below before submitting your Student Criminal History 
Check Statement: 

 

. Both the student and the student’s parent/guardian signed the form 

 

. All questions are answered completely and honestly. Students must answer 
“yes” to a question if they have ever been: 

.. Referred to any juvenile court or juvenile department for any crime or law 
violation; 
.. Placed in the jurisdiction of any juvenile court or juvenile department for 
any crime or law violation; 
.. Convicted of any crime or law violation (in juvenile or adult court); or 
.. Admitted to any crime or law violation 


 

. A written explanation is attached on a separate sheet of paper for any “yes” 
answers 

 

. The student’s social security number is provided only if the student is in a paid 
position with the District 

 

 

 

 

If you have any questions, please contact Human Resources at 503-399-3061.