Student Employment, 2026-27 School Year

Rev. 2-11-21 PAP-F023 Page 1 of 3

Paid Student Workers Criminal History Check Statement This application is for all Salem-Keizer School District student workers. Please answer all questions on this form. Incomplete information may cause your application to be delayed, rejected, or returned. Please print legibly and clearly. Do not complete this form if you want to volunteer. It is for paid employment only. Legal Last Name Legal First Name Full Middle Name Date of Birth MM/DD/YR

List other names you have used (if any): ____ Telephone: Email Address: __ Name of your parent/guardian: __ Name of school you currently attend: Salem-Keizer Student ID Number: Have you ever worked (for pay) for any school or school district before? Yes No If yes, where? Please answer each question truthfully. Not being truthful or not sharing required information may result in you not being allowed to work. If you answer "yes" to any question below, please explain on the next page. If you don't know how to answer a question, please call Human Resources/ Prevention and Protection at 503-399-3061.

1. Have you ever been convicted or adjudicated of a crime or law violation? Yes No
2. Have you ever been on probation for a crime or law violation? Yes No
3. Have you ever received diversion or attended classes for a crime or law violation? Yes No
4. Have you ever been referred to a juvenile department or court for a crime or law violation? Yes No
5. Have you ever been charged or cited for a crime or law violation that is not yet resolved? Yes No
6. Have you ever had a report of abuse, neglect or sexual misconduct filed against you? Yes No (With this question, we are not asking if you have experienced abuse. Rather, we are asking if there have been any allegations that you abused someone else. You are encouraged to reach out to your school counselor, school administrator, or another trusted adult if you have any questions or would like to discuss your personal situation.)
7. Have you ever been trespassed from any school, business, house, or any other property or event? Yes No
8. Have you ever been prohibited from contacting someone due to a restraining order, stalking order or no contact order? Yes No
9. Have you ever been expelled or suspended from a school? Yes No
10. Have you ever been investigated for a violation of school policy? Yes No

AUTHORIZATION TO RELEASE INFORMATION (RELEASE FROM LIABILITY AND WAIVER): To any law enforcement agencies, civil records authorities, Oregon Department of Education, Salem-Keizer Public School District, and other public or private schools or school districts: I authorize you to release to the Salem-Keizer School District any and all information and civil, criminal, and sexual misconduct 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, its 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, civil records authorities, Salem-Keizer Public School District, and other public or private schools or school districts 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 (Required for students under age 18) Date

Rev. 2-11-21 PAP-F023 Page 2 of 3

Your Name Explanation of Crimes/Offenses/Violations (Please complete this section if you answered "yes" to any questions on page 1).

Name of crime, violation or policy When did it happen? Explanation

Is there anything else you would like us to know?

Rev. 2-11-21 PAP-F023 Page 3 of 3

CHECKLIST Student Worker Criminal History Check Statement

Please review the checklist below before submitting your Student Worker Criminal History Check Statement: The student is required to sign this form. The student's parent/legal guardian must sign if the student is under age 18. The parent/legal guardian's signature is not required if the student is 18 years or older or has been emancipated through the Court.

All questions need to be answered completely and honestly. If you are unsure how to answer a question, please call Human Resources/Prevention and Protection at 503- 399-3061. Students who falsify their applications may not be allowed to work.

Complete the explanation section on page 2 for any "yes" answers.

Please do not complete this form if you want to volunteer. It is only for paid employment.

Please return completed forms to Human Resources: Email: prevention_protection@salkeiz.k12.or.us Mail: Salem-Keizer Public Schools, Human Resources, P.O. Box 12024, Salem, OR 97309.

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

Salem-Keizer Public Schools does not discriminate on the basis of race, color, religion, sex, sexual orientation, national origin, marital status, age or disability in its programs and activities.