404-5F
Sample Informed Consent Form
For Criminal History Background Check
Your School District Name and Number
Street Address
City, State, and Zip Code
Telephone Number
Date: ___________________
The following named individual has made application with this School District for employment or
provision of athletic coaching services or other extracurricular academic coaching services.
Full Name of Individual:_________________________________________________
(please print) Last First Middle
Maiden, Previous, Alias:__________________________________________________________
Date of Birth:_________________________ Sex (M or F): ________
Month/Day/Year
I authorize the Minnesota Bureau of Criminal Apprehension to disclose all criminal history record
information to ____________________________________________________________
pursuant to Minn. Stat. § 123B.03 for the purpose of _________________________________
_________________________________________ with this School District.
CONDITIONAL HIRING
: I understand that the School District may permit me to commence
my employment duties or provide athletic coaching services or other extracurricular academic
coaching services pending completion of the criminal history background check and acknowledge
and agree that my employment or services may be terminated based on the result of the background
check.
The expiration of this authorization shall be for a period no longer than one year from the date of
my signature.
__________________________________________ __________________
Signature of Applicant or Potential Service Provider Date
Subscribed and sworn to before me
this _____ day of __________, 20___.
_________________________________
Notary Public
The School District should forward this executed form, along
with a check or money order in the amount of $15.00 payable to
the “MN BCA” and a self-addressed, stamped envelope, to:
Minnesota Bureau of Criminal Apprehension
Criminal Justice Information Systems – CHA
1430 Maryland Avenue E.
St. Paul, MN 55106
404-6F
EMPLOYMENT AND SERVICES CRIMINAL HISTORY BACKGROUND CHECKS
NOTICE TO PARENTS AND GUARDIANS
The school district has adopted a policy, the purpose of which is to promote the physical, social,
and psychological well-being of its students. Pursuant to this policy, the school district shall seek
criminal history background checks for all applicants who receive an offer of employment with
the school district. The school district also shall seek criminal history background checks for all
individuals who are offered the opportunity to provide athletic coaching services or other
extracurricular academic coaching services to the school district, regardless of whether
compensation is paid. These positions include, but are not limited to, all athletic coaches,
extracurricular academic coaches, assistants, and advisors. The school district may elect to seek
criminal history background checks for other volunteers, independent contractors, and student
employees.
