EmailMe Form - Nurses & Non-Counseling Therapist Professionals

Full Name as it appears on your U. S. issued Identification *

First Last

Phone *

### - ### - ####

Email

Address *

Street Address City State / Province / Region Postal / Zip Code

Date of Birth *

MM / DD / YYYY

Social Security Number *

U.S. Identification Number *

United States of America issued identification number such as a valid drivers license, state ID, U.S. issued passport, or military ID

U. S. A., Name of State, or Name of Agency that issued your Drivers License or Identification Card *

Representing Agency *

If other please explain below

Assigned SISD Campus or Campuses

Have you ever been arrested? *

I understand and agree that SISD may obtain any criminal history record information pertaining to me. The district may obtain such information from the Department of Public Safety.

Have you received a deferred adjudication or been convicted by federal, state, or other law enforcement authorities or pleaded nolo contendre for violation of federal law, state law, county or municipal law, regulation or ordinance? (You must include any offense for which a fine of $100.00 or more was imposed. Do not include any offense that occurred before your eighteenth birthday.)

YES

NO

If you have been arrested please explain the type of offense (s)

By checking the box above, I hereby give my voluntary consent to a criminal history check, pursuant to Texas Education Code §22.0835. I understand that certain information obtained as a result of this criminal history check may preclude my participation in the SISD volunteer program. I agree to conform to all district policies and procedures.

I certify that all the information in this application is true and correct, and I further understand that my misstatement or omission of information may be grounds for disqualification. I understand this application becomes public record and is subject to disclosure. I understand that I have the right to review and challenge any negative information that would adversely impact my application.

Further, I hereby hold harmless, release, and fully discharge SISD, its agents, officers, or employees, from any and all liability, and claims, causes of action, costs and expenses which be attributed to my participation in the SISD Volunteer Program and/or any and all liability for the criminal history check and any action as a result of information obtained through the criminal history investigation.

Electronic Signature *

please click on box to sign electronically