SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

361/555-1234

Volunteer Consent and Authorization

for Release of Information

I hereby consent to and authorize XYZ Charter School (the “School”) to obtain from the Texas Department of Public Safety, (DPS), all criminal history record information that relates to me and agree that such information may be obtained each year while I am a volunteer at the School or at such other times as is necessary or appropriate to comply with the regulations governing the School or with School policy.

I understand that the criminal history record information obtained by the School may not be released or disclosed to any person except as provided under the regulations issued by the Commissioner of Education and that such records will be considered CONFIDENTIAL.

____________________________________ ____________________________________

Print Name Social Security Number

____________________________________ ___________________________________

Signature Date of Birth

____________________________________ ___________________________________

Date Signed Driver’s License Number and State

____________________________________ _____________________________________

Address Telephone Number

____________________________________ ___________________________________

City, State, Zip Other Name(s) of Record

I. 130