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Parent Volunteer Clearance Form

Parent Volunteer Clearance Form 

 

Student's Name                                                                  Grade            School Year                         

 

HOUSTON COUNTY SCHOOL SYSTEM

Consent Form

 

_____________________________SCHOOL(s)

I hereby authorize the Houston County School System to receive any criminal and/or driver's history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.

PLEASE TYPE OR PRINT THE FOLLOWING INFORMATION

 

 

Volunteer's Name                                                                                                                                           

             Last                                        First                             Middle                        

 

Home Phone #                                                                  

 

Cell #:                                                                       

 

 

Address                                                                                                                                                           

                        Street                                                                             City                State             ZIP

 

                                                                                                                                                                      

Sex                              Race                          Date of Birth                                                Social Security Number

 

                                                                                                                       

Driver's License Number/State ID Number

 

                                       

 All volunteers with the Houston County School System are considered child service organization personnel and have an obligation to report suspected child abuse to a school administrator.

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­­­­­­­­­­­­­­­­­­­­­­­_________________________________________________________

Signature of applicant

                                                                                                                                                                     

Notary Public Signature                                                                                       Date

 

 

(DO NOT WRITE BELOW THIS LINE)

 

 

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Perry Police Department

Perry, Georgia

______ I certify that I have conducted a search through the GCIC System on the person named above

            and the results were that, as of this date, this individual has no record on file.

 

            Record on the above named person is attached.

                                                                                 Name                                                                                          

 

                                                                                    Date