Request for Limited Criminal History Information
Filling out the LCH Form will fulfill all background checks for all HCCSC schools. Only one background check needed.
SUBJECT OF REQUEST:
Reason for filling out the form?
*
Please Select
Employment Recommendation
Volunteer/ Field Trip Request
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Address
Street Address Line 2
City
State / Province
Zip Code
State
Sex
*
Please Select
Female
Male
Social Security Number
*
Race
*
Please Select
Asian or Pacific Islander
Black
American Indian or Alaskan
Unknown
White
Hispanic
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Married Name 1
Married Name 2
Maiden Name
Other Name
State of Birth
*
Reason for background check?
*
(example: Field Trip, Band, classroom)
Reason for Request:
Applicant has applied for employment with a non-criminal justice organization or individual
Applicant is interested in becoming a volunteer or attend a field trip for the school corporation
Applicant is interested in being present in a school building, for example for a class party, have lunch with child in building, or other similar reason
Applicant has applied for a license and criminal history data is required by law to be provided in connection with the license.
School/Department Requesting For
*
Please Select
Administration Office
Andrews
Crestview
Flint Springs
Food Service
Health Services
Horace Mann
Huntington North High School
HN Athletics
Lincoln
Maintenance
PreSchool
Riverview
Roanoke
Salamonie
Special Services
Technology
Transportation
Post Prom
Grade level you are helping out with?
Please Select
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
Not Applicable
Name of Teacher you are volunteering to help?
School email
example@example.com
Principal Email
example@example.com
Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: